Pancreatic pseudotumors associated with multifocal idiopathic fibrosclerosis

Two patients with multifocal idiopathic fibrosclerosis and sclerosing cholangitis developed biliary obstruction due to a fibrotic pancreatic pseudotumor. The masslike fibrosis mimicked pancreatic carcinoma on sonography and cholangiopancreatography. In one patient sonography was successfully used to assess the response of the pseudotumor to corticosteroid therapy.     

Pharmacotherapy Choice Is Associated with 2-Year Mortality for Patients with Heart Failure and Reduced Ejection Fraction

Introduction

Factors associated with mortality for patients with heart failure and reduced ejection fraction (HFrEF) are known; however, the association between initial pharmacotherapy (IPT) and mortality is unclear in real-world settings.

Methods

Using a retrospective design and claims database, 14,359 Medicare patients with HFrEF from August 2010 to July 2015 were identified. Index date was first HF claim. IPT was mono- or combo-angiotensin-converting enzyme inhibitor (ACEI), angiotensin II receptor blocker (ARB), beta-blocker (BB), hydralazine–nitrate (HN), and aldosterone antagonist (AA) within 1 year post-index. A multivariable time-dependent Cox model estimated associations between IPT and 2-year all-cause mortality.

Results

Patients’ median age was 76 (70–82) years; 45.1% were female. Within 1 month post-index, 61.4% had IPT, 6.1% started after the first month, and 32.4% had no IPT in the first year. Of IPTs, 47.5% were mono-vasodilators (ACEI, ARB or HN), 23.3% mono-vasodilator + BB, 16.9% mono-BB, and 3.5% triple therapy [(ACEI or ARB) + BB + (HN or AA)]. Two-year mortality rate was 27.9%. Compared to mono-vasodilator therapy, patients initiating triple therapy had 29.3% lower risk of 2-year mortality; those on mono-BB or no IPT had higher mortality risk.

Conclusion

IPT was associated with decreased 2-year mortality risk. Timely consideration of triple IPT therapies may be warranted once HFrEF diagnosis is confirmed.

Funding

Novartis Pharmaceuticals Corp. located in East Hanover, NJ, USA.

     

Public clonotype usage identifies protective Gag-specific CD8+ T cell responses in SIV infection

Despite the pressing need for an AIDS vaccine, the determinants of protective immunity to HIV remain concealed within the complexity of adaptive immune responses. We dissected immunodominant virus-specific CD8⁺ T cell populations in Mamu-A*01⁺ rhesus macaques with primary SIV infection to elucidate the hallmarks of effective immunity at the level of individual constituent clonotypes, which were identified according to the expression of distinct T cell receptors (TCRs). The number of public clonotypes, defined as those that expressed identical TCR β-chain amino acid sequences and recurred in multiple individuals, contained within the acute phase CD8⁺ T cell population specific for the biologically constrained Gag CM9 (CTPYDINQM; residues 181–189) epitope correlated negatively with the virus load set point. This independent molecular signature of protection was confirmed in a prospective vaccine trial, in which clonotype engagement was governed by the nature of the antigen rather than the context of exposure and public clonotype usage was associated with enhanced recognition of epitope variants. Thus, the pattern of antigen-specific clonotype recruitment within a protective CD8⁺ T cell population is a prognostic indicator of vaccine efficacy and biological outcome in an AIDS virus infection.The global HIV pandemic demands an effective vaccine. However, while immunogenic vectors enter advanced clinical trials, the parameters on which to base measurements of efficacious immunity in a prospective manner remain unclear. Indeed, the recent Merck STEP trial failure has exposed our rudimentary understanding of protective determinants within the adaptive T cell response to HIV (1–3). It is established that specific CD8⁺ T cell immunity suppresses HIV replication in vivo and that certain patterns with respect to antigen targeting and MHC class I restriction are consistently associated with low levels of virus load (4–6). However, simple quantitative correlates, at least in peripheral blood, have proved elusive (7, 8). This paradox is exemplified by the SIV model, in which CD8⁺ T cell responses to the structurally constrained Gag CM9 epitope restricted by Mamu-A*01 are protective yet insufficient in terms of magnitude alone to define outcome (9, 10).In the absence of consistent numerical correlates of immune control, recent observational studies have focused on functional profiling in attempts to identify the properties that demarcate effective HIV-specific CD8⁺ T cell responses (11–15). Indeed, a broad consensus indicates that polyfunctionality within pathogen-specific T cell populations, which is related to the sensitivity of antigen recognition among other parameters, correlates with improved outcome measures (3, 16). However, the qualitative properties of CD8⁺ T cell populations are clearly affected by viral replication, and the extent to which such functional associates reflect deterministic attributes remains uncertain. Similarly, phenotypic analyses of HIV-specific CD8⁺ T cell populations have yet to provide definitive indicators of immune control (3). At a more fundamental level, a given cognate T cell response is defined by the nature of its constituent clonotypes, which are defined on the basis of their expressed TCRs and can be considered the elemental units of any antigen-specific T cell population. Thus, the primary interface between the virus and adaptive T cell immunity occurs at the level of TCR-mediated recognition of peptide-MHC antigen; these signal transduction events, in turn, dictate the ontogeny and biological characteristics of individual cognate T cells in vivo. Given the seminal importance of clonotype-dependent TCR-mediated recognition events, it is not unreasonable to propose that the potential efficacy of a composite virus-specific CD8⁺ T cell population might depend on the idiosyncrasies with which individual cognate TCRs engage the targeted viral antigen.In a previous study, we examined the clonotypic composition of immunodominant CD8⁺ T cell populations in acute SIV infection to illuminate the role of TCR usage in the process of mutational immune escape (17). In the present study, we conducted a detailed prospective study of vaccine-induced SIV-specific CD8⁺ T cell responses to the same immunodominant epitopes to establish whether the mobilized antigen-specific TCR repertoire can influence virologic outcome.     

Planning locally relevant Internet programs for secondary prevention of cardiovascular disease

Background

Although the Internet has been shown to be an effective tool for supporting behavioural change in other chronic diseases, less in known about the efficacy of, or need for, Internet-based interventions in the prevention of coronary heart disease (CHD).

Aims

We investigated computer literacy, consumer need and perceived usefulness of the Internet as a secondary prevention tool in people with CHD.

Methods

A two-step mixed-method process was used that included a survey and two focus groups. The 12-item survey explored participants' access and confidence using the Internet. For the focus groups, we used standard methodology.

Results

We recruited 66 (88% response rate) consecutive cardiac patients; age 36–73 years (mean 64 ± 13), mostly male (85%), whose primary language was predominantly English (67%). Seventy percent had a home computer with Internet access but only 20% reported researching their heart-health online. There was polarity between those with and without Internet access. Further, we found less women than men could complete online forms (p = 0.03) and that participants aged over 65 years were less likely to access the Internet (p < 0.01) and had lower confidence (p < 0.01) than younger counterparts. Focus groups revealed challenges of an online secondary prevention service, but participants valued relevant, practical advice and placed strong emphasis on simple web design.

Conclusion

Using a mixed-methods process we collected locally sensitive information about Internet usage and recommendations for future online health-management strategies. Some patients have more confidence using the Internet, therefore a range of multi-technological secondary prevention interventions should be considered based on individual need.     

Nocturnal care interactions with patients in critical care units.

BACKGROUND: Sleep deprivation is common in critically ill patients and may have long-term effects on health outcomes and patients' morbidity. Clustering nocturnal care has been recommended to improve patients' sleep. OBJECTIVES: To (1) examine the frequency, pattern, and types of nocturnal care interactions with patients in 4 critical care units; (2) analyze the relationships among these interactions and patients' variables (age, sex, acuity) and site of admission to the intensive care unit; and (3) analyze the differences in patterns of nocturnal care activities among the 4 units. METHODS: A randomized retrospective review of the medical records of 50 patients was used to record care activities from 7 PM to 7 AM in 4 critical care units. RESULTS: Data consisted of interactions during 147 nights. The mean number of care interactions per night was 42.6 (SD 11.3). Interactions were most frequent at midnight and least frequent at 3 AM. Only 9 uninterrupted periods of 2 to 3 hours were available for sleep (6% of 147 nights studied). Frequency of interactions correlated significantly with patients' acuity scores (r = 0.32, all Ps < .05). A sleep-promoting intervention was documented for only 1 of the 147 nights, and 62% of routine daily baths were provided between 9 PM and 6 AM. CONCLUSIONS: The high frequency of nocturnal care interactions left patients few uninterrupted periods for sleep. Interventions to expand the period around 3 AM when interactions are least common could increase opportunities for sleep.     

Evolving as nurse educators in problem-based learning through a community of faculty development.

Effective faculty development programs are of paramount importance in this era of profound change in nursing education driven by baccalaureate-degree entry to practice and the concurrent implementation of college/university collaborative partnerships in Ontario, Canada. The overall purpose of this study was to design, disseminate, and evaluate a faculty development program involving nursing faculty from the McMaster University, Mohawk College, and Conestoga College. In keeping with selected conceptual models and responses to a needs assessment, faculty participated in a collaborative faculty development program that included a planned workshop, a mentorship program, and regular faculty development activities. This article presents the qualitative program evaluation component that included focus group discussions and subsequent content analysis to gain an understanding of the experiences and meaning of the faculty who participated in the faculty development program. The overarching theme was that the faculty experienced a sense of evolving as nurse educators in problem-based learning (PBL) through a community of faculty development. The following themes emerged: becoming certain in the midst of uncertainty; developing collegial trust and community; embracing PBL; valuing faculty development; and evolving as a nurse educator in PBL through faculty development. The results attest to the benefits of a collaborative faculty development program, guide future faculty development, and promote mastery in PBL.     

Guiding mothers' management of health problems of very low birth-weight infants

OBJECTIVE: Explore the feasibility, usefulness, and outcomes of a pilot program to support mothers in developing competencies for managing health problems of their very low birth-weight (VLBW) infants in partnership with the primary care clinician (PCC). DESIGN: In a randomized study, mothers who received guided participation (GP) and printed guidelines for managing VLBW infant health problems were compared with mothers who received only the guidelines and standard care (GL group). SAMPLE: All mothers (GP = 20; GL = 11) were at least 18 years old and English speaking. Infants were all VLBW (< or =1,500 g). INTERVENTION: GP began during the infant's neonatal intensive care unit stay and continued with public health nurses (PHNs) and a family service clinician through the infant's first 4 postterm months. Measurements: Intervention feasibility and usefulness were assessed with maternal and clinician feedback. Outcomes included maternal and clinician appraisal of mothers' use of clinical resources and mothers' perceptions of primary-care quality and the family-PCC relationship. RESULTS: Intervention feasibility and usefulness were supported. GP and GL groups did not differ significantly on outcomes. CONCLUSIONS: Findings indicate a longer intervention period, GP organized by infant problem episodes, and enhancement of the PHN role in the context of interdisciplinary and interagency collaboration.     

Management of pain during abortion

The purpose of this study was to determine the effects of three cognitive behavioural strategies in the management of abortion pain. The interventions were drawn from the multidimensional model of pain suggested by the gate control theory. Forty patients undergoing abortion with local anaesthesia were instructed in one of four interventions: relaxation, pleasant imagery, analgesic imagery, and a pain discussion (attention control) group. Pain was measured using Johnson's two-dimensional graphic rating scales labelled sensation and distress. Speed of recovery and analgesic use were included as objective dependent measures. No significant differences were found among the four groups on any dependent measures although subjects receiving the pleasant imagery intervention reported the lowest subjective ratings of pain sensation and distress. Findings are discussed in terms of past research and implications for the management of acute pain experienced during abortion.