Search

Background: Idiopathic multicentric Castleman disease (iMCD) is a rare inflammatory disorder mediated by excessive proinflammatory cytokine signaling, most notably by interleukin 6 (IL-6). IL-6-induced extramedullary hematopoiesis (EMH) has been reported in murine models of iMCD. Herein we present four cases of iMCD with EMH in humans., Case Series: The index case is a 24-year-old white woman who presented with pancytopenia, hepatosplenomegaly, and diffuse lymphadenopathy (LAD) with EMH in core lymph node biopsies. We then searched ACCELERATE, a Castleman disease (CD) natural history registry, and identified three additional CD cases with EMH reported in biopsies: A 23-year-old Asian man with fatigue, edema, LAD, and splenomegaly; a 20-year-old white man with fever, dyspnea, LAD, and hepatosplenomegaly; and a 50-year-old white man with constitutional symptoms, LAD, and myelodysplastic syndrome in bone marrow with a KRAS mutation., Results: All four patients presented with thrombocytopenia and fever and/or markedly elevated C-reactive protein. Patient 1 had iMCD-NOS (not otherwise specified) with severe thrombocytopenia, reticulin fibrosis in bone marrow, small volume LAD and organomegaly but no anasarca. The other three patients had iMCD-TAFRO (thrombocytopenia, anasarca, reticulin fibrosis, renal dysfunction, organomegaly). Two had mixed CD and two had hypervascular CD in lymph nodes. All four had bone marrow hypercellularity and megakaryocyte hyperplasia and two had reticulin fibrosis., Conclusions: This case series demonstrates that EMH can be seen in CD, particularly in iMCD-TAFRO. Given the similarity of this finding to previous murine models of IL-6-induced marrow and lymph node changes we hypothesize that this is an IL-6-mediated phenomenon., (© 2024 The Author(s). European Journal of Haematology published by John Wiley & Sons Ltd.)

Objectives: Long-haul truck drivers experience multiple challenges, including increased health risks. A large percentage of professional truck drivers (PTDs) suffer from numerous chronic physical health conditions such as obesity, hypertension, diabetes, heart disease, sleep disorders, etc.) as well as poor mental health and social challenges. Furthermore, this population experiences numerous barriers related to accessing health care services including primary care and resources to improve their health. PTDs living in rural and remote areas are at higher risk. The objective of this study is to understand the views of PTDs and the trucking industry on health and personalized healthcare interventions and services., Methods: In-depth semi-structured interviews were conducted with twenty-six individuals with contextual knowledge and experience in the trucking ecosystem, to better understand the needs, expectations, and preferences of PTDs based in New Brunswick (Canada), related to their health (physical, mental, and social). Analysis of the audiotape recording was conducted using thematic content analysis., Results: Three major themes emerged from the qualitative analysis describing PTDs' health needs, existing health and preventive services, as well as recommendations for personalized healthcare interventions and services to be implemented: (1) "My life as a trucker!" Understanding needs and challenges, (2) "Taking care of myself, do you think it is easy while you're on the road?" Describing drivers and motivators for better health, and (3) "Can you hear what we need?" Translating needs into recommendations for tailored health services and preventative services., Conclusion: A highly demanding work environment and lack of timely access to integrated primary care negatively affect PTDs' health. Results of this study shed light on how to tailor primary care to improve its responsiveness and adequacy to PTDs' needs and realities. PTDs-sensitive integrated services, including multicomponent interventions (health education, coaching for lifestyle changes, and social support), are still lacking within the New Brunswick health system., (© 2024. The Author(s).)

Background: Individual injecting practices (e.g., intramuscular injecting, lack of skin cleaning) are known risk factors for injection drug use-associated bacterial and fungal infections; however, social contexts shape individual behaviours and health outcomes. We sought to synthesize studies assessing potential social determinants of injecting-related infections and treatment outcomes., Methods: We searched five databases for studies published between 1 January 2000 and 18 February 18 2021 (PROSPERO CRD42021231411). We included studies of association (aetiology), assessing social determinants, substance use, and health services exposures influencing development of injecting-related infections and treatment outcomes. We pooled effect estimates via random effects meta-analyses., Results: We screened 4,841 abstracts and included 107 studies. Several factors were associated with incident or prevalent injecting-related infections: woman/female gender/sex (adjusted odds ratio [aOR] 1.57, 95% confidence interval [CI] 1.36-1.83; n=20 studies), homelessness (aOR 1.29, 95%CI 1.16-1.45; n=13 studies), cocaine use (aOR 1.31, 95%CI 1.02-1.69; n=10 studies), amphetamine use (aOR 1.74, 95%CI 1.39-2.23; n=2 studies), public injecting (aOR 1.40, 95%CI 1.05-1.88; n=2 studies), requiring injecting assistance (aOR 1.78, 95%CI 1.40-2.27; n=8 studies), and use of opioid agonist treatment (aOR 0.92, 95%CI 0.89-0.95; n=9 studies). Studies assessing outcomes during treatment (e.g., premature hospital discharge) or afterward (e.g., rehospitalization; all-cause mortality) typically had smaller sample sizes and imprecise effect estimates., Conclusions: Injecting-related infections and treatment outcomes may be shaped by multiple social contextual factors. Approaches to prevention and treatment should look beyond individual injecting practices towards addressing the social and material conditions within which people live, acquire and consume drugs, and access health care., Competing Interests: DECLARATION OF INTERESTS M.B. reports personal fees from AbbVie, a pharmaceutical research and development company, and 469 grants and personal fees from Gilead Sciences, a research-based biopharmaceutical company, outside of the submitted work. The other authors report no competing interests.

Quick, easy access to data-driven community risk assessment principles and to related community risk reduction activities can encourage fire departments to learn about, conduct, and complete district risk reduction practices. With the ultimate goal of creating web-based community risk assessment and community risk reduction resources, we first evaluated fire department needs. Over an eight-month period, a quantitative online survey was administered to officers from 45 unique fire departments in 44 Kentucky counties, with follow-up qualitative telephone interviews administered to 11 fire officials. Mixed-methods, sequential analysis of the data clarified the "what," "who," and "how" of risk analysis/reduction activities, noted what specific reduction activities departments used to prepare for and mitigate risk, and named specific facilitators and barriers to risk assessment and reduction. Respondents described data use for community risk assessment and for planning community risk reduction activities; how a lack of time, personnel, and funding impacts community risk assessment and community risk reduction activities; and how to involve both firefighters and the community in the process. Innovative solutions such as a website containing resources on how to assess community risk information along with resources such as community risk assessment/ reduction education, program planning, and tools, can assist departments to use community risk assessment data in the development of community risk reduction activities., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Paul R. Clark reports financial support was provided by Federal Emergency Management Agency, United States., (Copyright © 2023 Elsevier Ltd and International Society of Burns Injuries. All rights reserved.)

Background and Aims: Injection drug use-associated bacterial and fungal infections are increasingly common, and social contexts shape individuals' injecting practices and treatment experiences. We sought to synthesize qualitative studies of social-structural factors influencing incidence and treatment of injecting-related infections., Methods: We searched PubMed, EMBASE, Scopus, CINAHL and PsycINFO from 1 January 2000 to 18 February 2021. Informed by Rhodes' 'risk environment' framework, we performed thematic synthesis in three stages: (1) line-by-line coding; (2) organizing codes into descriptive themes, reflecting interpretations of study authors; and (3) consolidating descriptive themes into conceptual categories to identify higher-order analytical themes., Results: We screened 4841 abstracts and included 26 qualitative studies on experiences of injecting-related bacterial and fungal infections. We identified six descriptive themes organized into two analytical themes. The first analytical theme, social production of risk, considered macro-environmental influences. Four descriptive themes highlighted pathways through which this occurs: (1) unregulated drug supply, leading to poor drug quality and solubility; (2) unsafe spaces, influenced by policing practices and insecure housing; (3) health-care policies and practices, leading to negative experiences that discourage access to care; and (4) restrictions on harm reduction programmes, including structural barriers to effective service provision. The second analytical theme, practices of care among people who use drugs, addressed protective strategies that people employ within infection risk environments. Associated descriptive themes were: (5) mutual care, including assisted-injecting and sharing sterile equipment; and (6) self-care, including vein health and self-treatment. Within constraining risk environments, some protective strategies for bacterial infections precipitated other health risks (e.g. HIV transmission)., Conclusions: Injecting-related bacterial and fungal infections are shaped by modifiable social-structural factors, including poor quality unregulated drugs, criminalization and policing enforcement, insufficient housing, limited harm reduction services and harmful health-care practices. People who inject drugs navigate these barriers while attempting to protect themselves and their community., (© 2023 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Technological advances in the field of histocompatibility have allowed us to define anti-human leukocyte antigen (HLA) antibody specificity at the allelic level. However, how allele-specific antibodies affect organ allocation is poorly studied. We examined allelic specificities of class I HLA antibodies in 6726 consecutive serum samples from 2953 transplant candidates and evaluated their impact on the corresponding crossmatch and organ allocation. Out of 17 class I HLA antigens represented by >1 allele in the LABScreen single antigen bead assay, 12 had potential allele-specific reactivity. Taking advantage of our unbiased cohort of deceased donor-candidate testing (123,135 complement-dependent cytotoxicity crossmatches between 2014 and 2017), we estimated that the presence of allele-specific antibody detected using a single antigen bead assay (median fluorescence intensity, >3000) against only the rare allele was a poor predictor of a positive complement-dependent cytotoxicity crossmatch, with a positive predictive value of 0% to 7%, compared with 52.5% in allele-concordant class I HLA antibodies against A or B locus antigens. Further, we confirmed allele-specific reactivity using flow crossmatch in 3 scenarios: A11:01/A11:02, A68:01/A68:02, and B44:02/B44:03. Our results suggest that allele-specific antibodies may unnecessarily exclude transplant candidates (up to 10%) from organ offers by overcalling unacceptable antigens; incorporation of selective reactivity pattern in allocation may promote precision matching and more equitable allocation., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Melissa Yeung reports a relationship with One Lambda Inc that includes: consulting or advisory. Mike Chen reports a relationship with One Lambda Inc that includes: employment. Jar-How Lee reports a relationship with One Lambda Inc that includes: employment., (Copyright © 2023 American Society of Transplantation & American Society of Transplant Surgeons. Published by Elsevier Inc. All rights reserved.)

Chronic HIV infection is characterized by persistent inflammation despite antiretroviral therapy (ART). Cannabinoids may help reduce systemic inflammation in people with HIV (PWH). To assess the effects of oral cannabinoids during HIV, ten PWH on ART were randomized ( n = 5/group) to increasing doses of oral Δ9-tetrahydrocannabinol (THC): cannabidiol (CBD) combination (2.5:2.5-15:15 mg/day) capsules or CBD-only (200-800 mg/day) capsules for 12 weeks. Blood specimens were collected prospectively 7-21 days prior to treatment initiation and at weeks 0 to 14. Plasma cytokine levels were determined via Luminex and ELISA. Immune cell subsets were characterized by flow cytometry. HIV DNA/RNA were measured in circulating CD4 T-cells and sperm by ultra-sensitive qPCR. Results from both arms were combined for statistical analysis. Plasma levels of IFN-γ, IL-1β, sTNFRII, and REG-3α were significantly reduced at the end of treatment ( p ˂ 0.05). A significant decrease in frequencies of PD1+ memory CD4 T-cells, CD73+ regulatory CD4 T-cells, and M-DC8+ intermediate monocytes was also observed ( p ˂ 0.05), along with a transient decrease in CD28-CD57+ senescent CD4 and CD8 T-cells. Ki-67+ CD4 T-cells, CCR2+ non-classical monocytes, and myeloid dendritic cells increased over time ( p ˂ 0.05). There were no significant changes in other inflammatory markers or HIV DNA/RNA levels. These findings can guide future large clinical trials investigating cannabinoid anti-inflammatory properties.

Background: To learn about the experiences of people who use drugs, specifically opioids, in the Halifax Regional Municipality (HRM), in Nova Scotia, Canada during the COVID-19 pandemic through qualitative interviews with people who use drugs and healthcare providers (HCP). This study took place within the HRM, a municipality of 448,500 people [1]. During the pandemic many critical services were interrupted while overdose events increased. We wanted to understand the experiences of people who use drugs as well as their HCPs during the first year of the pandemic., Methodology: We conducted a qualitative study using semi-structured interviews with 13 people who use drugs and 6 HCPs, including physicians who work in addiction medicine (3), a pharmacist, a nurse, and a community-based opioid agonist therapy (OAT) program staff member. Participants were recruited within HRM. Interviews were held via phone or videoconference due to social distancing directives. Interviews focused on the challenges people who use drugs and HCPs faced during the pandemic as well as elicited perspectives on a safe supply of drugs and the associated barriers and facilitators to the provision of a safe supply., Results: Of the 13 people who use drugs who participated in this study, ages ranged from 21-55 years (mean 40). Individuals had spent on average 17 years in HRM. Most people who use drugs (85%, n = 11) utilized income assistance, the Canadian Emergency Response Benefit, or disability support. Many had experienced homelessness (85%, n = 11) and almost half (46%, n = 6) were currently precariously housed in the shelter system. The main themes among interviews (people who use drugs and HCPs) were housing, accessing healthcare and community services, shifts in the drug supply, and perspectives on safe supply., Conclusions: We identified several challenges that people who use drugs face in general, but especially during the COVID-19 pandemic. Access to services, housing support, and interventions to use safely at home were limited. As many challenges faced by people who use drugs exist outside of COVID-19, we concluded that the formal and informal interventions and changes in practice that were made to support people who use drugs should be sustained well past the end of the pandemic. The need for enhanced community supports and a safe supply of drugs, despite its complicated nature, is essential for the health and safety of people who use drugs in HRM, especially during COVID-19., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Matthew Herder is a member of the Patented Medicine Prices Review Board, Canada’s national drug pricing regulator, and receives honoraria for his public service. This does not alter our adherence to PLOS ONE policies on sharing data and materials. No other conflicts of interest were reported, (Copyright: © 2023 Comeau et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

ABO compatibility is important for kidney transplantation, with longer waitlist times for blood group B kidney transplant candidates. However, kidneys from non-A 1 (eg, A 2 ) subtype donors, which express less A antigen, can be safely transplanted into group B recipients. ABO subtyping is routinely performed using anti-A 1 lectin, but DNA-based genotyping is also possible. Here, we compare lectin and genotyping testing. Lectin and genotype subtyping was performed on 554 group A deceased donor samples at 2 transplant laboratories. The findings were supported by 2 additional data sets of 210 group A living kidney donors and 124 samples with unclear lectin testing sent to a reference laboratory. In deceased donors, genotyping found 65% more A 2 donors than lectin testing, most with weak lectin reactivity, a finding supported in living donors and samples sent for reference testing. DNA sequencing and flow cytometry showed that the discordances were because of several factors, including transfusion, small variability in A antigen levels, and rare ABO∗A2.06 and ABO∗A2.16 sequences. Although lectin testing is the current standard for transplantation subtyping, genotyping is accurate and could increase A 2 kidney transplant opportunities for group B candidates, a difference that should reduce group B wait times and improve transplant equity., (Copyright © 2022 American Society of Transplantation & American Society of Transplant Surgeons. Published by Elsevier Inc. All rights reserved.)

People living with HIV (PLWH) may be at risk for poor immunogenicity to certain vaccines, including the ability to develop immunological memory. Here, we assessed T-cell immunogenicity following three SARS-CoV-2 vaccine doses in PLWH versus uninfected controls. Blood was collected from 38 PLWH on antiretroviral therapy and 24 age-matched HIV-negative controls, pre-vaccination and after 1st/2nd/3rd dose of SARS-CoV-2 vaccines, without prior SARS-CoV-2 infection. Flow cytometry was used to assess ex vivo T-cell immunophenotypes and intracellular Tumor necrosis factor (TNF)-α/interferon(IFN)-γ/interleukin(IL)-2 following SARS-CoV-2-Spike-peptide stimulation. Comparisons were made using Wilcoxon signed-rank test for paired variables and Mann-Whitney for unpaired. In PLWH, Spike-specific CD4 T-cell frequencies plateaued post-2nd dose, with no significant differences in polyfunctional SARS-CoV-2-specific T-cell proportions between PLWH and uninfected controls post-3rd dose. PLWH had higher frequencies of TNFα+CD4 T-cells and lower frequencies of IFNγ+CD8 T-cells than seronegative participants post-3rd dose. Regardless of HIV status, an increase in naive, regulatory, and PD1+ T-cell frequencies was observed post-3rd dose. In summary, two doses of SARS-CoV-2 vaccine induced a robust T-cell immune response in PLWH, which was maintained after the 3rd dose, with no significant differences in polyfunctional SARS-CoV-2-specific T-cell proportions between PLWH and uninfected controls post-3rd dose.

Objectives: In the Canadian context of universal health-care coverage, income inequalities are understudied as potentially predictive of the timings and patterns of repeat hospitalizations for diabetes, despite this condition requiring self-care practices entailing appreciable out-of-pocket expenses in daily life. In this study, we examined the relationships between income disparities and risk of earlier readmission for diabetes and commonly comorbid chronic conditions in the working-age population., Methods: The cohort study exploited 2006 population census data linked longitudinally to 3 years of hospital records from the Discharge Abstract Database among adults 25 to 64 years of age. Multiple regression survival models were used to test the associations of income group with cause-specific times to rehospitalization for diabetes (types 1 and 2) and 5 additional conditions, controlling for other individual sociodemographics., Results: The mean time to rehospitalization for diabetes was 223 days (N=4,540). Compared with those in the lowest income quintile, the adjusted risk of earlier readmission was significantly lower among inpatients in the highest income quintile for diabetes (hazard ratio [HR]=0.89; 95% confidence interval [CI], 0.80 to 0.99) and for the diabetes-concordant conditions of congestive heart failure (HR=0.81; 95% CI, 0.66 to 0.99) and hypertension (HR=0.85; 95% CI, 0.76 to 0.95). No significant associations between income and readmission intervals were observed for the discordant conditions of angina, asthma and chronic obstructive pulmonary disease., Conclusions: Delays in rehospitalization for diabetes and concordant conditions among the most affluent suggest the persistence of income-mediated differences in individuals' ability to manage these conditions. Further research is needed to understand the specific financial burdens of disease management on patients and their households that may accelerate the risk of repeat hospitalization., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: We have previously reported on the benefits of Pre-Surgical Exercise Training (PreSET) on physical fitness and social interactions in subjects awaiting bariatric surgery (BS). However, data are needed to know whether these benefits are maintained post-BS., Objectives: The purpose of this paper was to evaluate the effect of PreSET on physical activity (PA) level, physical fitness, PA barriers, and quality of life (QoL) 1 year (1-Y) after BS., Methods: Of the 30 participants randomized into two groups (PreSET and usual care), 25 were included in the final analysis. One year after BS, time spent in different PA intensities and number of steps were assessed with an accelerometer. Before BS and until 1-Y after BS, physical fitness was assessed with symptom-limited cardiac exercise test, 6-min walk test (6MWT), and sit-to-stand, half-squat, and arm curl tests. QoL, PA barriers, and PA level were evaluated with questionnaires., Results: The number of steps (7460 vs 4287) and time spent in light (3.2 vs 2.2 h/day) and moderate (0.6 vs 0.3 h/day) PA were higher in the PreSET group 1-Y after BS. The changes in 6MWT heart cost (1.3 vs 0.6 m/beats/min), half-squat test (38.8 vs 10.3 s), and BMI (- 16.8 vs - 13.5 kg/m 2 ) were significantly greater in the PreSET group compared to those in the usual care group. No other significant difference between groups was observed., Conclusion: The addition of the PreSET to individual lifestyle counseling seems effective to improve PA level and submaximal physical fitness 1-Y after BS. Studies with larger cohorts are now required to confirm these results. The trial was registered at clinicaltrials.gov (NCT01452230).

Background: Experts recommend physical activity (PA) to optimize bariatric surgery (BS) results. However, evidence on the effect of PA before BS is missing. The aim of this study was to assess the impact of adding a Pre-Surgical Exercise Training (PreSET) to an interdisciplinary lifestyle intervention on physical fitness, quality of life, PA barriers, and anthropometric parameters of subjects awaiting BS., Methods: Thirty candidates for BS (43.2 ± 9.2 years, 47.5 ± 8.1 kg/m 2 ) have been randomized in two groups: one group following the PreSET (endurance and strength training) and another receiving usual care. Before and after 12 weeks, we assessed physical fitness with a battery of tests (symptom-limited exercise test, 6-min walk test (6MWT), sit-to-stand test, half-squat test, and arm curl test), quality of life with the laval questionnaire, and PA barriers with the physical exercise belief questionnaire., Results: One control group subject abandoned the study. Subjects in the PreSET group participated in 60.0 % of the supervised exercise sessions proposed. Results showed significant improvements in the 6MWT (17.4 ± 27.2 vs. -16.4 ± 42.4 m; p = 0.03), half-squat test (17.1 ± 17.9 vs. -0.9 ± 14.5 s; p = 0.05), arm curl repetitions (4.8 ± 2.3 vs. 1.0 ± 4.1; p = 0.01), social interaction score (10.7 ± 12.5 vs. -2.1 ± 11.0 %; p = 0.02), and embarrassment (-15.6 ± 10.2 vs. -3.1 ± 17.8 %; p = 0.02) in completers (n = 8) compared to the non-completers (n = 21). No significant difference between groups in BMI and other outcomes studied was observed after the intervention., Conclusions: Adding a PreSET to an individual lifestyle counselling intervention improved physical fitness, social interactions, and embarrassment. Post-surgery data would be interesting to confirm these benefits on the long term.

Objective. Measuring NKG2C(+)CD57(+) natural killer (NK) cell expansion to investigate NK responses against human cytomegalovirus (HCMV) and assessing relationships with adaptive immunity against HCMV. Methods. Expansion of NKG2C(+)CD57(+) NK was measured in peripheral blood mononuclear cells (PBMC) from groups distinguished by HCMV and human immunodeficiency virus (HIV) infection status. Anti-HCMV antibody levels against HCMV-infected MRC-5 cell lysate were assessed by ELISA and HCMV-specific CD8(+) T cell responses characterized by intracellular flow cytometry following PBMC stimulation with immunodominant HCMV peptides. Results. Median NK, antibody, and CD8(+) T cell responses against HCMV were significantly greater in the HCMV/HIV coinfected group than the group infected with CMV alone. The fraction of CMV-specific CD8(+) T cells expressing CD28 correlated inversely with NKG2C(+)CD57(+) NK expansion in HIV infection. Conclusion. Our data reveal no significant direct relationships between NK and adaptive immunity against HCMV. However, stronger NK and adaptive immune responses against HCMV and an inverse correlation between NKG2C(+)CD57(+) NK expansion and proliferative reserve of HCMV-specific CD8(+) T cells, as signified by CD28 expression, indicate parallel evolution of NK and T cell responses against HCMV in HIV infection. Similar aspects of chronic HCMV infection may drive both NK and CD8(+) T cell memory inflation.

The objective of this systematic review was to appraise current knowledge on the impact of physical activity (PA) and physical fitness (PF) on the health of class II and III obese subjects and bariatric surgery (BS) patients. All original studies were searched using four databases (Medline®, Scopus®, CINAHL and Sportdiscus). Two independent investigators selected studies assessing the impact of PA or PF on specific health outcomes (anthropometric parameters, body composition, cardiometabolic risk factors, PF, wellness) in adults with a body mass index ≥35 kg m(-2) or in BS patients. Conclusions were drawn based on a rating system of evidence. From 3,170 papers identified, 40 papers met the inclusion criteria. The vast majority of studies were recently carried out with a predominance of women. Less than one-third of these studies were experimental and only three of them were of high quality. Each study reported at least one beneficial effect of PA or PF. However, a lack of high-quality studies and heterogeneity in designs prevented us from finding high levels of evidence. In conclusion, although results support the importance of PA and PF to improve the health of this population, higher-quality trials are required to strengthen evidence-based recommendations., (© 2014 The Authors. obesity reviews © 2014 International Association for the Study of Obesity.)

Objective: To examine the impact of the first nurse-implemented tele-intensive care unit (tele-ICU) staffing model, with the intent that shared nursing vigilance and collaboration can decrease patient complications potentially impacting patient outcomes., Subjects and Materials: A quantitative study used a pre-post program design of 90 staff nurses in the Adult Critical Care Unit, 10 tele-ICU nurses, and 1,308 patient participants at Providence Alaska Medical Center (Anchorage, AK). Twelve months of baseline data were collected: Acute Physiology and Chronic Health Evaluation severity-adjusted ICU length of stay (LOS), ICU mortality, protocols for the prevention of ventilator-associated pneumonia (VAP), ventilator bundle compliance (stress ulcer and venous thrombosis prophylaxis), and glucose control. Follow-up data were obtained using the same outcomes examined for baseline: 9 months for the nurse and only an additional 3 months with the addition of physician monitoring services., Results: Data demonstrated post-tele-ICU implementation improvements as follows: severity-adjusted LOS decrease, 15% (222 patient-days saved); severity-adjusted ICU mortality decrease, 14% (20 lives saved); compliance improvement of "at-risk" patients, restraint documentation 26% improvement; ventilator bundle compliance, 6% increase; and VAP, 13% decrease in patient-days., Conclusions: Collaboration between bedside and remote nurses in conjunction with the use of tele-ICU program technology positively impacts critical care patient outcomes. Effective nursing collaboration and communication and improved patient outcomes can be attained through nursing vigilance and attention to best practices or health system protocols and the use of smart technology such as the population management tools in the tele-ICU program.

Mesenchymal stem cells (MSCs) are a promising cell source for the treatment of musculoskeletal disease. However, MSC chondrogenesis in 3D culture generates constructs whose macroscopic (bulk) mechanical properties are inferior to constructs formed with chondrocytes. To investigate where and why these deficits in functionality arise, we assessed the local (microscopic) properties of cell-laden hydrogel constructs. Both chondrocyte- and MSC-laden constructs showed pronounced depth dependency, with ~3.5 and ~11.5 fold decreases in modulus from the surface to central regions, respectively. Importantly, in the surface region, properties were similar, suggesting that MSCs can produce matrix of mechanical equivalence to chondrocytes, but only in conditions of maximal nutrient support. Dynamic culture on an orbital shaker (which enhances diffusion) attenuated depth-dependent disparities in mechanics and improved the bulk properties compared to free swelling conditions (225 to 438 kPa for chondrocytes, 122 to 362 kPa for MSCs). However, properties in MSC-based constructs remained significantly lower due to persistent mechanical deficits in central regions. MSC viability in these central regions decreased markedly, with these changes apparent as early as day 21, while chondrocyte viability remained high. These findings suggest that, under optimal nutrient conditions, MSCs can undergo chondrogenesis and form functional tissue on par with that of the native tissue cell type. However, the lack of viability and matrix production in central regions suggests that chondrogenic MSCs do not yet fully recapitulate the advanced phenotype of the chondrocyte, a cell that is optimized to survive (and thrive) in a mechanically challenging and nutrient-poor environment.

Introduction: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is well recognized for its efficiency in morbidly obese patients. Anastomotic strictures present in 5-15% of cases and have a significant impact on the patient's quality of life. Endoscopic balloon dilation is the recommended treatment but management of refractory cases is challenging., Presentation of Case: Two patients with anastomotic stenoses refractory to dilations were treated with fully covered esophageal stents. Both cases presented early stent migration. The first patient finally underwent surgical revision of the anastomosis. For the second patient, a double-layered stent was installed after the first incident. After the migration of this second stent, three sessions of intralesional injection of triamcinolone acetonide were performed. Both patients were free of obstructive symptoms at a follow-up of 9 months., Discussion: Treatment of post-gastric bypass strictures with stents is based on years of successful experience with endoscopic stenting of malignant esophageal strictures, gastric outlet obstruction in addition to anastomotic stenoses after esophageal cancer surgery. The actual prosthesis are however inadequate for the particularities of the LRYGB anastomosis with a high migration rate. Intralesional corticosteroid injection therapy has been reported to be beneficial in the management of refractory benign esophageal strictures and seems to have prevented recurrence of the stenosis in this post-LRYGB., Conclusion: Stents are aimed at preventing a complex surgical reintervention but are not yet specifically designed for that indication. Local infiltration of corticosteroids at the time of dilation may prevent recurrence of the anastomotic stricture., (Copyright © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

In 2001, St Joseph Hospital in Augusta, Ga, reorganized its patient safety initiatives to improve patient care outcomes. By 2004, we decided to focus the many clinical projects toward one goal, reducing inpatient mortality. One year later, raw mortality decreased by 29% and severity-adjusted mortality decreased by 25.5%.

In 2001 through 2003, our agency received deficiencies in infection-control practices, specific to wound care, from JCAHO and Medicare surveyors. Efforts to correct this pattern were initially unsuccessful. As a result, in 2003, an interdisciplinary performance improvement team was formed to assess, plan, and implement a wound care program utilizing research-based best practice. The changes in process, practice, and education resulted in success, with improvement evidenced by 100% acceptable practice during our 2004 unannounced JCAHO/Medicare survey, a declined rate of wound infection per our Medicare OASIS Adverse Event Report, and a decrease in wound care patient visits.

In general, the unannounced JCAHO survey is a more positive and patient-focused process than surveys in the past. Staff are able to demonstrate and explain what they actually do in their job on a day-to-day basis rather than stating policies. In the continuous survey-readiness process, there is less emphasis on document preparation and more on effective care. The process is appropriately clinically focused.

Nosocomial pneumonia is the second most costly infection occurring in US hospitals. It is associated with high mortality and morbidity and is considered one of the most difficult infections to diagnose and prevent. In 1999, St Joseph Hospital formed a multidisciplinary Ventilator-Associated Pneumonia Performance Improvement Team to tackle the myriad of issues involved in the prevention of ventilator-associated pneumonia and the care of this high-risk patient population. The accomplishments of the team were significant, with a 95% reduction in ventilator-associated pneumonia.

Study Objective: Our objective was to determine the extent to which patterns of diagnostic and therapeutic practice differ among hospitals caring for acutely ill hospitalized asthmatic patients in a single city., Design: Our study comprised a retrospective review of the records of patients admitted to the hospital for the treatment of acute asthma., Setting: Three large teaching hospitals in Boston were the setting., Patients: One hundred twenty-seven patients between 18 and 50 years of age who were admitted to the medical services specifically for the treatment of asthma were studied., Interventions: There were no interventions., Measurements and Main Results: For this group of patients with similar histories of asthma, clinical presentation, and severity of asthma, the diagnostic tests used within 12 hours of admission and the frequency and volume of diagnostic laboratory testing throughout the admission differed significantly among the three hospitals. Spirometry, the test bearing most directly on the severity of the asthmatic attack, was not used routinely as a criterion for admission or discharge at any of the hospitals. Other tests of uncertain efficacy, such as chest x-ray films, were used frequently at some of the hospitals. Patients at all three hospitals were treated similarly with intensive combined regimens of methylxanthines, sympathomimetics, and corticosteroids and had similar mean lengths of stay. The use of chest physical therapy, which has not yet been demonstrated to be effective in acute asthma, differed significantly among the three hospitals., Conclusions: We conclude that considerable variability exists in the diagnostic evaluation of acutely ill hospitalized asthmatic patients in the three hospitals; little variability exists in the pharmacologic treatment of these patients. In the absence of data on outcome regarding functional improvement and reductions in morbidity, we are unable to recommend a preferred pattern of practice from this study.