Interprofessional communication between surgery trainees and nurses in the inpatient wards: Why time and space matter

Optimal interprofessional communication (IPC) is broadly viewed as a prerequisite to providing quality patient care. In this study, we explored the enablers and barriers to IPC between surgical trainees and ward nurses with a view towards improving IPC and the quality of surgical patient care. We conducted an ethnography in two academic centres in Canada totalling 126 hours of observations and 32 semi-structured interviews with trainees and nurses. Our findings revealed constraints on IPC between trainees and nurses derived from contested meanings of space and time. Trainees experienced the contested spatial boundaries of the surgical ward when they perceived nurses to project a sense of territoriality. Nurses expressed difficulty getting trainees to respond and attend to pages from the ward, and to have a poor understanding of the nurses’ role. Contestations over time spent in training and patient care were found in trainee–nurse interactions, wherein trainees perceived seasoned nurses to devalue their clinical knowledge on the ward. Nurses viewed the limited time that trainees spent in clinical rotation in the ward as adversely affecting communication. This study underscores that challenges to enhancing IPC at academic health centres are rooted in team and professional cultures. Efforts to improve IPC should therefore: identify and target the social and cultural dimensions of healthcare team member relations; recognise how power is deployed and experienced in ways that negatively impact IPC; and enhance an understanding and appreciation in the temporal and spatial dimensions of IPC.     

Restriction spectrum imaging improves MRI-based prostate cancer detection

Purpose

To compare the diagnostic performance of restriction spectrum imaging (RSI), with that of conventional multi-parametric (MP) magnetic resonance imaging (MRI) for prostate cancer (PCa) detection in a blinded reader-based format.

Methods

Three readers independently evaluated 100 patients (67 with proven PCa) who underwent MP-MRI and RSI within 6 months of systematic biopsy (N = 67; 23 with targeting performed) or prostatectomy (N = 33). Imaging was performed at 3 Tesla using a phased-array coil. Readers used a five-point scale estimating the likelihood of PCa present in each prostate sextant. Evaluation was performed in two separate sessions, first using conventional MP-MRI alone then immediately with MP-MRI and RSI in the same session. Four weeks later, another scoring session used RSI and T2-weighted imaging (T2WI) without conventional diffusion-weighted or dynamic contrast-enhanced imaging. Reader interpretations were then compared to prostatectomy data or biopsy results. Receiver operating characteristic curves were performed, with area under the curve (AUC) used to compare across groups.

Results

MP-MRI with RSI achieved higher AUCs compared to MP-MRI alone for identifying high-grade (Gleason score greater than or equal to 4 + 3=7) PCa (0.78 vs. 0.70 at the sextant level; P < 0.001 and 0.85 vs. 0.79 at the hemigland level; P = 0.04). RSI and T2WI alone achieved AUCs similar to MP-MRI for high-grade PCa (0.71 vs. 0.70 at the sextant level). With hemigland analysis, high-grade disease results were similar when comparing RSI + T2WI with MP-MRI, although with greater AUCs compared to the sextant analysis (0.80 vs. 0.79).

Conclusion

Including RSI with MP-MRI improves PCa detection compared to MP-MRI alone, and RSI with T2WI achieves similar PCa detection as MP-MRI.

     

The Use of an Automated,Portable Glucose Control System for Overnight Glucose Control in Adolescents and Young Adults With Type 1 Diabetes

OBJECTIVE

A key milestone in progress towards providing an efficacious and safe closed-loop artificial pancreas system for outpatient use is the development of fully automated, portable devices with fault detection capabilities to ensure patient safety. The ability to remotely monitor the operation of the closed-loop system would facilitate future physician-supervised home studies.

RESEARCH DESIGN AND METHODS

This study was designed to investigate the efficacy and safety of a fully automated, portable, closed-loop system. The Medtronic Portable Glucose Control System (PGCS) consists of two subcutaneous glucose sensors, a control algorithm based on proportional-integral-derivative with insulin feedback operating from a BlackBerry Storm smartphone platform, Bluetooth radiofrequency translator, and an off-the-shelf Medtronic Paradigm Veo insulin pump. Participants with type 1 diabetes using insulin pump therapy underwent two consecutive nights of in-clinic, overnight, closed-loop control after a baseline open-loop assessment.

RESULTS

Eight participants attended for 16 overnight studies. The PGCS maintained mean overnight plasma glucose levels of 6.4 ± 1.7 mmol/L (115 ± 31 mg/dL). The proportion of time with venous plasma glucose <3.9, between 3.9 and 8 (70 and 144 mg/dL), and >8 mmol/L was 7, 78, and 15%, respectively. The proportion of time the sensor glucose values were maintained between 3.9 and 8 mmol/L was greater for closed-loop than open-loop (84.5 vs. 46.7%; P < 0.0001), and time spent <3.3 mmol/L was also reduced (0.9 vs. 3%; P < 0.0001).

CONCLUSIONS

These results suggest that the PGCS, an automated closed-loop device, is safe and effective in achieving overnight glucose control in patients with type 1 diabetes.Intensive management of type 1 diabetes is necessary to achieve near-normal glucose levels to obtain A1C values associated with a reduced risk of microvascular and macrovascular complications. Large-scale studies have revealed that in some patients, such efforts are associated with an increased risk of severe hypoglycemia (1). The effects of intensive management on the incidence of severe hypoglycemia may be even greater in children and adolescents (2), particularly in the setting of diminished counterregulatory hormone responses (3,4). Despite the development of insulin analogs and increasing use of insulin pump therapy, approximation of physiologic insulin delivery has not been achievable by most. Presently, children with an A1C <7% spend approximately one-quarter of each 24-h period with glucose levels >11.1 mmol/L (200 mg/dL) (3). Even with use of sensor-augmented pump therapy, the epitome of technology currently available to patients, one-third or less patients achieve an A1C target <7% (5,6), and the incidence of severe hypoglycemia is not reduced.Currently, there are two principal approaches to β-cell replacement therapy. Islet-cell transplantation has demonstrated promising results in recovery of hypoglycemia awareness and reduction in episodes of hypoglycemia (7). Unfortunately, there are risks associated with immunosuppressive therapy (8), and currently, <75% of patients are insulin-independent 4 years after transplant (7). The second and, arguably, more promising therapeutic approach to β-cell replacement is a closed-loop artificial pancreas incorporating a continuous glucose sensor, insulin pump, and control algorithm.Commercially available insulin pumps and glucose sensors are considered sufficiently accurate for use in a closed-loop system (9,10). Despite the delays inherent in absorption and action of insulin delivered subcutaneously, previous studies have demonstrated superiority of such systems over standard pump therapy (11–18). Automation of insulin delivery is not a novel concept (11,12); however, the closed-loop system in many reports was not fully automated. In some studies, sensor glucose was entered manually every 5 to 15 min (15–17) or changes to the pump delivery rate were made manually by a physician or research nurse (13–17). Furthermore, insulin delivery in studies published to date was based on a control algorithm contained in a desktop or laptop computer (11–18), implying that the system was not readily portable or practical in an ambulatory setting. A key milestone in progress toward making a closed-loop artificial pancreas system available for outpatient use is the development of fully automated, portable devices with fault detection capabilities to ensure safety. An additional desirable feature of these devices is the ability to remotely monitor the operation of the closed-loop system via data transmitted over a wireless network, facilitating future physician-supervised home studies.The Medtronic Portable Glucose Control System (PGCS) is a portable, automated, closed-loop device consisting of a BlackBerry Storm smartphone (Research in Motion, Waterloo, ON, Canada), an unmodified Medtronic Paradigm Veo insulin pump, two MiniLink REAL-Time Transmitters (Medtronic Minimed, Northridge, CA) modified to transmit at 1-min rather than 5-min intervals, two Enlite glucose sensors (Medtronic Minimed), and a Medtronic custom-built radiofrequency translator, as illustrated in Fig. 1.Open in a separate windowFigure 1The components of the Medtronic PGCS.In this study, we describe the safety and efficacy of the PGCS, an automated closed-loop device, focusing on overnight glucose control in adolescents and young adults with type 1 diabetes.     

Dual effects of the alloresponse by Th1 and Th2 cells on acute and chronic rejection of allotransplants

The contribution of direct and indirect alloresponses by CD4⁺ Th1 and Th2 cells in acute and chronic rejection of allogeneic transplants remains unclear. In the present study, we addressed this question using a transplant model in a single MHC class I‐disparate donor–recipient mouse combination. BALB/c‐dm2 (dm2) mutant mice do not express MHC class I L^d molecules and reject acutely L^d+ skin grafts from BALB/c mice. In contrast, BALB/c hearts placed in dm2 mice are permanently accepted in the absence of chronic allograft vasculopathy. In this model, CD4⁺ T cells are activated following recognition of a donor MHC class I determinant, L^d 61–80, presented by MHC Class II A^d molecules on donor and recipient APC. Pre‐transplantation of recipients with L^d 61–80 peptide emulsified in complete Freund's adjuvant induced a Th1 response, which accelerated the rejection of skin allografts, but it had no effect on cardiac transplants. In contrast, induction of a Th2 response to the same peptide abrogated the CD8⁺ cytotoxic T cells response and markedly delayed the rejection of skin allografts while it induced de novo chronic rejection of heart transplants. This shows that Th2 cells activated via indirect allorecognition can exert dual effects on acute and chronic rejection of allogeneic transplants.     

Myofibrillar myopathy caused by a mutation in the motor domain of mouse MyHC IIb

Ariel is a mouse mutant that suffers from skeletal muscle myofibrillar degeneration due to the rapid accumulation of large intracellular protein aggregates. This fulminant disease is caused by an ENU-induced recessive mutation resulting in an L342Q change within the motor domain of the skeletal muscle myosin protein MYH4 (MyHC IIb). Although normal at birth, homozygous mice develop hindlimb paralysis from Day 13, consistent with the timing of the switch from developmental to adult myosin isoforms in mice. The mutated myosin (MYH4(L342Q)) is an aggregate-prone protein. Notwithstanding the speed of the process, biochemical analysis of purified aggregates showed the presence of proteins typically found in human myofibrillar myopathies, suggesting that the genesis of ariel aggregates follows a pathogenic pathway shared with other conformational protein diseases of skeletal muscle. In contrast, heterozygous mice are overtly and histologically indistinguishable from control mice. MYH4(L342Q) is present in muscles from heterozygous mice at only 7% of the levels of the wild-type protein, resulting in a small but significant increase in force production in isolated single fibres and indicating that elimination of the mutant protein in heterozygotes prevents the pathological changes observed in homozygotes. Recapitulation of the L342Q change in the functional equivalent of mouse MYH4 in human muscles, MYH1, results in a more aggregate-prone protein.     

Hypofibrinolysis in type 2 diabetes: the role of the inflammatory pathway and complement C3

Aims/hypothesis

Plasminogen activator inhibitor-1 (PAI-1) has been regarded as the main antifibrinolytic protein in diabetes, but recent work indicates that complement C3 (C3), an inflammatory protein, directly compromises fibrinolysis in type 1 diabetes. The aim of the current project was to investigate associations between C3 and fibrinolysis in a large cohort of individuals with type 2 diabetes.

Methods

Plasma levels of C3, C-reactive protein (CRP), PAI-1 and fibrinogen were analysed by ELISA in 837 patients enrolled in the Edinburgh Type 2 Diabetes Study. Fibrin clot lysis was analysed using a validated turbidimetric assay.

Results

Clot lysis time correlated with C3 and PAI-1 plasma levels (r?=?0.24, p?<?0.001 and r?=?0.22, p?<?0.001, respectively). In a multivariable regression model involving age, sex, BMI, C3, PAI-1, CRP and fibrinogen, and using log-transformed data as appropriate, C3 was associated with clot lysis time (regression coefficient 0.227 [95% CI 0.161, 0.292], p?<?0.001), as was PAI-1 (regression coefficient 0.033 [95% CI 0.020, 0.064], p?<?0.05) but not fibrinogen (regression coefficient 0.003 [95% CI ?0.046, 0.051], p?=?0.92) or CRP (regression coefficient 0.024 [95% CI ?0.008, 0.056], p?=?0.14). No correlation was demonstrated between plasma levels of C3 and PAI-1 (r?=??0.03, p?=?0.44), consistent with previous observations that the two proteins affect different pathways in the fibrinolytic system.

Conclusions/interpretation

Similarly to PAI-1, C3 plasma levels are independently associated with fibrin clot lysis in individuals with type 2 diabetes. Therefore, future studies should analyse C3 plasma levels as a surrogate marker of fibrinolysis potential in this population.     

Nonalcoholic steatohepatitis and the metabolic syndrome

Nonalcoholic fatty liver disease (NAFLD) is a major form of chronic liver disease in adults and children. It is one of the consequences of the current obesity epidemic, and can progress to nonalcoholic steatohepatitis (NASH), characterized by steatosis, inflammation, and progressive fibrosis, ultimately leading to cirrhosis and end-stage liver disease. The factors implicated in this progression are poorly understood. NASH is closely associated with obesity and the metabolic syndrome. Recent studies emphasize the role of insulin resistance, oxidative stress, lipid peroxidation, and cytokine release in the development of NASH. This review summarizes the current knowledge on the etiology and pathomechanism of NASH and the role of the metabolic syndrome in NASH development.     

Extent of Follow-Up on Abnormal Cancer Screening in Multiple California Public Hospital Systems: A Retrospective Review

BackgroundInequitable follow-up of abnormal cancer screening tests may contribute to racial/ethnic disparities in colon and breast cancer outcomes. However, few multi-site studies have examined follow-up of abnormal cancer screening tests and it is unknown if racial/ethnic disparities exist.ObjectiveThis report describes patterns of performance on follow-up of abnormal colon and breast cancer screening tests and explores the extent to which racial/ethnic disparities exist in public hospital systems.DesignWe conducted a retrospective cohort study using data from five California public hospital systems. We used multivariable robust Poisson regression analyses to examine whether patient-level factors or site predicted receipt of follow-up test.Main MeasuresUsing data from five public hospital systems between July 2015 and June 2017, we assessed follow-up of two screening results: (1) colonoscopy after positive fecal immunochemical tests (FIT) and (2) tissue biopsy within 21 days after a BIRADS 4/5 mammogram.Key ResultsOf 4132 abnormal FITs, 1736 (42%) received a follow-up colonoscopy. Older age, Medicaid insurance, lack of insurance, English language, and site were negatively associated with follow-up colonoscopy, while Hispanic ethnicity and Asian race were positively associated with follow-up colonoscopy. Of 1702 BIRADS 4/5 mammograms, 1082 (64%) received a timely biopsy; only site was associated with timely follow-up biopsy.ConclusionDespite the vulnerabilities of public-hospital-system patients, follow-up of abnormal cancer screening tests occurs at rates similar to that of patients in other healthcare settings, with colon cancer screening test follow-up occurring at lower rates than follow-up of breast cancer screening tests. Site-level factors have larger, more consistent impact on follow-up rates than patient sociodemographic traits. Resources are needed to identify health system–level factors, such as test follow-up processes or data infrastructure, that improve abnormal cancer screening test follow-up so that effective health system–level interventions can be evaluated and disseminated.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07657-4.KEY WORDS: safety-net system, cancer screening, colon cancer, breast cancer, cancer disparities     

Efficacy of interferon alpha-2b induction therapy before retreatment for chronic hepatitis C.

BACKGROUND/AIMS: Chronic hepatitis C (HCV) patients who have failed previous treatment have low sustained viral response (SVR) rates with repeat treatment. We evaluated whether interferon (IFN) induction during retreatment improves response rates. METHODS: Two randomized, controlled trials were conducted in chronic HCV patients who failed IFN. In Study 1, patients received IFN 3 MU daily plus ribavirin (RBV) 1000 mg/day for 4 weeks, followed by IFN 3 MU TIW plus RBV 1000 mg/day for 44 weeks (induction; n=232), or IFN 3 MU TIW plus RBV 1000 mg/day for 48 weeks (non-induction; n=237). In Study 2, patients received IFN 5 MU B.I.D. plus RBV 1000-1200 mg/day for 2 weeks, followed by pegylated IFN (PEG-IFN) 75-150 mug weekly plus RBV 1000-1200 mg/day for 46 weeks (induction; n=201), or PEG-IFN 75-150 mug weekly plus RBV 1000-1200 mg/day for 48 weeks (non-induction; n=206). The primary end point for both trials was SVR. RESULTS: Induction did not increase SVR compared with non-induction, but did increase the on-treatment response among genotype non-1 patients in Study 2. By intention-to-treat (ITT) analysis, SVR in Study 1 was 13% for induction vs. 9% for non-induction (P=NS). In Study 2 (ITT), SVR was 20% for induction vs. 24% for non-induction (P=NS). However, by non-ITT analysis of Study 2, genotype non-1-previous non-responders showed significantly higher response rates with induction than non-induction. CONCLUSION: For chronic HCV patients who have failed IFN, induction with retreatment does not improve SVR, but may be beneficial for patients with genotype non-1 HCV.