Survival of pre-viable preterm infants in the United States: A systematic review and meta-analysis

The objective of this paper is to review observational studies that addressed the survival of pre-viable gestations in the United States. We searched PubMed, Ovid, CINAHL, and Web of Knowledge for studies reporting survival of infants born at <24 gestational weeks and/or <500 g in the United States and published between January 2003 and January 2013. The full texts of 70 articles were examined and a total of 15 studies qualified and were selected. We analyzed fixed-effect and random-effects models for eight studies on survival to discharge. Pooled survival to discharge in the random-effects model was 45.9% (95% CI: 41.1–51.7) and 39.7% in the fixed-effect model (95% CI: 38.8–40.7). Studies differed by pre-viable survival measures and epochs (1985–2009). Protective factors included antenatal corticosteroids, neonatal resuscitation, and intensive care. The current survival threshold for pre-viable infants warrants reconsideration of the limits of viability. Protective factors that enhance survival should be considered in the management of these infants.     

Cutaneous histoplasmosis with prominent parasitization of epidermal keratinocytes: report of a case

Disseminated histoplasmosis most commonly occurs in immunosuppressed individuals and involves the skin in approximately 6% of patients. Cutaneous histoplasmosis with an intraepithelial‐predominant distribution has not been described. A 47‐year‐old man was admitted to our institution with fever and vancomycin‐resistant enterococcal bacteremia. He had been diagnosed with T‐cell prolymphocytic leukemia 4 years earlier and had undergone matched‐unrelated‐donor stem cell transplant 2 years earlier; on admission, he had relapsed disease. His medical history was significant for disseminated histoplasmosis 6 months before admission, controlled with multiple antifungal regimens. During this final hospitalization, the patient developed multiple 2–5 mm erythematous papules, a hemorrhagic crust across the chest, shoulders, forearms, dorsal aspect of the fingers, abdomen and thighs. Skin biopsy revealed clusters of oval yeast forms mostly confined to the cytoplasm of keratinocytes and within the stratum corneum; scattered organisms were present in the underlying superficial dermis without any significant associated inflammatory infiltrate. Special stains and immunohistochemical studies confirmed these to be Histoplasma organisms. We highlight this previously unrecognized pattern of cutaneous histoplasmosis to ensure its prompt recognition and appropriate antifungal therapy.     

The role of mindfulness skills in terms of anxiety-related cognitive risk factors among college students with problematic alcohol use

Background: The aim of the current study was to examine the associations between the specific mindfulness skills of observing, describing, awareness, nonjudgment, and nonreactivity in terms of anxiety sensitivity (AS), distress tolerance (DT), and intolerance of uncertainty (IU) among college students with problematic alcohol use. Methods: Participants were 202 (69.3% male; M_age = 18.96, SD = 2.24, range = 18–45 years) undergraduate college students with problematic alcohol use who completed self-report measures for course credit. Results: Results indicated that after controlling for the effects of gender, smoking status, marijuana use status, and negative affectivity, greater use of the mindfulness skill of observing was associated with higher AS, greater describing was associated with lower AS and higher DT, greater nonjudgment was associated with lower AS and IU and higher DT, and greater nonreactivity was associated with increased DT. Awareness did not significantly predict any of the examined risk factors. Conclusions: These results suggest that specific mindfulness skills are associated with a greater tolerance of physiological, emotional, and uncertain states. An important next step will be to examine whether mindfulness skills are associated with decreased problematic alcohol use due to improvements in these anxiety-related risk factors.     

Stress Hormone Exposure Reduces mGluR5 Expression in the Nucleus Accumbens: Functional Implications for Interoceptive Sensitivity to Alcohol

Escalations in alcohol drinking associated with experiencing stressful life events and chronic life stressors may be related to altered sensitivity to the interoceptive/subjective effects of alcohol. Indeed, through the use of drug discrimination methods, rats show decreased sensitivity to the discriminative stimulus (interoceptive) effects of alcohol following exposure to the stress hormone corticosterone (CORT). This exposure produces heightened elevations in plasma CORT levels (eg, as may be experienced by an individual during stressful episodes). We hypothesized that decreased sensitivity to alcohol may be related, in part, to changes in metabotropic glutamate receptors-subtype 5 (mGluR5) in the nucleus accumbens, as these receptors in this brain region are known to regulate the discriminative stimulus effects of alcohol. In the accumbens, we found reduced mGluR5 expression (immunohistochemistry and Western blot) and decreased neural activation (as measured by c-Fos immunohistochemistry) in response to a moderate alcohol dose (1 g/kg) following CORT exposure (7 days). The functional role of these CORT-induced adaptations in relation to the discriminative stimulus effects of alcohol was confirmed, as both the systemic administration of 3-Cyano-N-(1,3-diphenyl-1H-pyrazol-5-yl)benzamide (CDPPB) an mGluR5 positive allosteric modulator and the intra-accumbens administration of (R,S)-2-Amino-2-(2-chloro-5-hydroxyphenyl)acetic acid sodium salt (CHPG) an mGluR5 agonist restored sensitivity to alcohol in discrimination-trained rats. These results suggest that activation of mGluR5 may alleviate the functional impact of the CORT-induced downregulation of mGluR5 in relation to sensitivity to alcohol. Understanding the contribution of such neuroadaptations to the interoceptive effects of alcohol may enrich our understanding of potential changes in subjective sensitivity to alcohol during stressful episodes.     

An exploration of nurse-physician perceptions of collaborative behaviour

Interprofessional collaboration is a key element in providing safe, holistic patient care in the acute care setting. Trended data at a community hospital indicated opportunities for improvement in collaboration on micro, meso, and macro levels. The aim of this survey study was to assess the current state of collaboration between frontline nurses and physicians at a non-academic acute care hospital. A convenience sample of participants was recruited with a final respondent sample of 355 nurses and 82 physicians. The results indicated that physicians generally perceived greater collaboration than nurses. Physician ratings did not vary by primary practice area, whereas nurse ratings varied by clinical practice area. Nurse ratings were the lowest in the operating room and the highest in the emergency department. Text-based responses to an open-ended question were analysed by role and coded by two independent research teams. Emergent themes emphasised the importance of rounding, roles, respect, and communication. Despite recognition of the need for improved collaboration and relational behaviours, strategies to improve collaborative practice must be fostered at the meso level by organisational leaders and customised to address micro-level values. At the study site, findings have been used to address and improve collaboration towards the goal of becoming a high reliability organisation.