Cultural Competency Challenges Certified Nursing Assistants Experience in Providing Palliative Care.

PURPOSE: Increasing racial and ethnic diversity in U.S. nursing facilities has necessitated the provision of more culturally competent care. This study explored the cultural challenges in providing palliative care from the perspective of certified nursing assistants (CNAs) and nurses in nursing facilities. METHOD: A thematic analysis approach was used to examine data from semi-structured interviews with 12 CNAs and 11 nurses from six nursing facilities in a U.S. Midwestern state. RESULTS: Four themes emerged from the data: Cultural Needs Expressed by Residents, Cultural Needs Expressed by Family Members, Accommodating Residents' Cultural Needs, and Organizational Responses to Cultural Competency Challenges. CONCLUSION: Results highlighted the training variations on diversity and cultural competency issues and the varying cultural competency levels possessed by staff. To support residents' culture-related needs, staff need education and support. Organizations can provide foundational resources for this diversity of cultural expression, including providing more culturally diverse programming facilities. [Journal of Gerontological Nursing, 50(7), 35-41.].

CCK Receptor Inhibition Reduces Pancreatic Tumor Fibrosis and Promotes Nanoparticle Delivery.

The poor prognosis for pancreatic ductal adenocarcinoma (PDAC) patients is due in part to the highly fibrotic nature of the tumors that impedes delivery of therapeutics, including nanoparticles (NPs). Our prior studies demonstrated that proglumide, a cholecystokinin receptor (CCKR) antagonist, reduced fibrosis pervading PanIN lesions in mice. Here, we further detail how the reduced fibrosis elicited by proglumide achieves the normalization of the desmoplastic tumor microenvironment (TME) and improves nanoparticle uptake. One week following the orthotopic injection of PDAC cells, mice were randomized to normal or proglumide-treated water for 3-6 weeks. Tumors were analyzed ex vivo for fibrosis, vascularity, stellate cell activation, vascular patency, and nanoparticle distribution. The histological staining and three-dimensional imaging of tumors each indicated a reduction in stromal collagen in proglumide-treated mice. Proglumide treatment increased tumor vascularity and decreased the activation of cancer-associated fibroblasts (CAFs). Additionally, PANC-1 cells with the shRNA-mediated knockdown of the CCK2 receptor showed an even greater reduction in collagen, indicating the CCK2 receptors on tumor cells contribute to the desmoplastic TME. Proglumide-mediated reduction in fibrosis also led to functional changes in the TME as evidenced by the enhanced intra-tumoral distribution of small (<12 nm) Rhodamine-loaded nanoparticles. The documented in vivo, tumor cell-intrinsic anti-fibrotic effects of CCK2R blockade in both an immunocompetent syngeneic murine PDAC model as well as a human PDAC xenograft model demonstrates that CCK2R antagonists, such as proglumide, can improve the delivery of nano-encapsulated therapeutics or imaging agents to pancreatic tumors.

Nuances in the interpretation and utility of donor-derived cell-free DNA in lung transplantation following allogeneic hematopoietic stem cell transplantation - Case report.

Respiratory complications following allogeneic HSCT can lead to severe morbidity and mortality. Lung transplantation (LT) is a potential treatment for select patients with late-onset non-infectious pulmonary complications post-HSCT. Donor-derived cell-free DNA (dd-cfDNA) is a noninvasive biomarker for monitoring the health of allografts following LT. However, its utility in a multi-genome setting of LT after HSCT has not yet been clinically validated. Here we describe a case of a 75-year-old, male patient who underwent single-lung transplantation for BOS related to chronic GVHD and presented with persistently elevated dd-cfDNA levels. In a surveillance biopsy, the patient was diagnosed with mild acute cellular rejection at three months. The patient's lung function remained stable, and the reported dd-cfDNA levels decreased after the rejection episode but remained elevated above levels that would be considered quiescent for LT alone. In this unique setting, as 3 different genomes contributed to the dd-cfDNA% reported value, valuable insight was obtained by performing further analysis to separate the specific SNPs to identify the contribution of recipient, lung-donor, and HSCT-donor cfDNA. This study highlights the potential utility of dd-cfDNA in the multi-genome setting of lung transplant post-HSCT, nuances that need to be considered while interpreting the results, and its value in monitoring lung rejection.

Refractory Autonomic Instability in Mild Traumatic Brain Injury: A Case Report.

Although the specific relationship between concussion and the autonomic nervous system (ANS) has not been fully elucidated, it is generally understood that the pathologic response after a traumatic brain injury (TBI) is linked with systolic cardiac dysfunction. In this case, we present a patient with multiple concussion injuries over a five-year period who exhibited severe cardiac and autonomic dysfunction, in addition to prolonged impairments in vestibular function, oculomotor function, cognitive function, and headaches. The patient is a 28-year-old male with a past medical history of multiple concussions, with the first concussion occurring due to a skiing accident in January 2015. He initially presented in October 2016 after sustaining a concussion due to a motor vehicle accident (MVA) without loss of consciousness (LOC) two weeks prior. In July 2017, the patient was involved in another MVA with a positive head strike and without LOC, causing his third concussion. After each of his first three concussions, he displayed various symptoms that eventually resolved. In October 2020, the patient suffered a syncopal ground-level fall with several minutes of LOC due to dehydration and lightheadedness, leading to his fourth concussion. His fourth concussion resulted in chronic autonomic dysfunction with resting tachycardia refractory to medical management, and he eventually underwent a cardiac ablation. Although the patient underwent a cardiac ablation, his tachycardia and dysautonomia still cause dysfunction in his daily life. With millions of people living with the sequelae of TBI, the recognition and treatment of autonomic dysfunction should be a continued focus in brain injury research.

The Value of Negative Urinary Dipstick Tests for Haematuria in Patients Undergoing Surveillance for Low-grade Ta Urothelial Cancer: A Two-stage Prospective Clinical Study in 524 Patients.

Background and objective: The risk of first recurrence beyond 5 yr for patients with low-grade (LG) Ta non-muscle-invasive bladder cancer (NMIBC) is low enough to consider discontinuing cystoscopic surveillance at that point. However, a positive urinary dipstick test for haematuria (UDH) during and beyond the period of cystoscopic surveillance can disrupt plans to cease surveillance because the association between UDH positivity and recurrence in LG Ta NMIBC is unknown. In a two-stage study, we evaluated this association and explored the role of UDH negativity in predicting the absence of recurrence. Methods: Because of previously demonstrated changes in recurrence patterns over time, two prospective cohorts were assessed: an "exploratory" cohort (January 2007-March 2008) and a "validation" cohort (November 2017-August 2018). UDH was performed before flexible cystoscopy. Patient, operative, and surveillance data have been recorded prospectively using standard pro forma sheets since 1978 in our institution. Only patients with primary LG Ta pTa NMIBC were included for analysis. Key findings and limitations: We assessed 231 patients in the exploratory group and 293 in the validation group. The proportion of smokers (67% vs 70%; p = 0.5) and mean follow-up (72.2 vs 79.9 mo; p = 0.2) were similar between the groups. The recurrence rate was higher in the exploratory group (19% vs 11%; p = 0.009), as was the UDH positivity rate (37% vs 11%; p < 0.001). The specificity and negative predictive value were 64% and 83% in the exploratory group, and 90% and 90%, respectively, in the validation group. These values increased further for the subgroup with solitary primary tumours the subgroup without recurrence for 3 yr. Conclusions and clinical implications: UDH negativity has a high probability of being associated with the absence of recurrence in small LG Ta NMIBC and could be an inexpensive adjunct during surveillance. Ongoing validation, which started in 2019, is being performed in a now-nationalised Scottish protocol in which UDH replaces cystoscopy in years 2 and 4 for patients in the low-risk group. Patient summary: We investigated the accuracy of a dipstick test for blood in the urine for patients undergoing surveillance for low-grade noninvasive bladder cancer. We found that a negative dipstick test result was highly associated with the absence of tumour recurrence, particularly for patients with the lowest risk. These findings have been introduced into a national protocol designed to reduce the frequency of telescopic inspection of the bladder during surveillance to reduce the burden for patients.

The inflammatory response to birth requires MyD88 and is driven by both mother and offspring.

Birth is an inflammatory event for the newborn, characterized by elevations in interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α peripherally and/or centrally, as well as changes in brain microglia. However, the mechanism(s) underlying these responses is unknown. Toll-like receptors (TLRs) play crucial roles in innate immunity and initiate inflammatory cascades upon recognition of endogenous or exogenous antigens. Most TLR signaling depends on the adaptor molecule myeloid differentiation primary response 88 (MyD88). We independently varied MyD88 gene status in mouse dams and their offspring to determine whether the inflammatory response to birth depends on MyD88 signaling and, if so, whether that signaling occurs in the offspring, the mother, or both. We find that the perinatal surges in plasma IL-6 and brain expression of TNF-α depend solely on MyD88 gene status of the offspring, whereas postnatal increases in plasma IL-10 and TNF-α depend on MyD88 in both the pup and dam. Interestingly, MyD88 genotype of the dam primarily drives differences in offspring brain microglial density and has robust effects on developmental neuronal cell death. Milk cytokines were evaluated as a possible source of postnatal maternal influence; although we found high levels of CXCL1/GROα and several other cytokines in ingested post-partum milk, their presence did not require MyD88. Thus, the inflammatory response previously described in the late-term fetus and newborn depends on MyD88 (and, by extension, TLRs), with signaling in both the dam and offspring contributing. Unexpectedly, naturally-occuring neuronal cell death in the newborn is modulated primarily by maternal MyD88 gene status.

Daily, seasonal, and long-distance movements inferred from Fastloc-GPS telemetry of immature green turtles (Chelonia mydas) at a high-latitude, mid-ocean developmental site.

To characterize the movements and habitat use of juvenile green turtles (Chelonia mydas) in benthic developmental habitat, we deployed Fastloc-GPS-enabled satellite transmitters on 16 individuals captured as part of a multi-decade study of green turtles on the Bermuda Platform. We characterized residence areas, distinct use areas within them, and seasonal movements based on an average of 562 Fastloc-GPS positions and 284 tracking days per turtle. We estimated residence area sizes using traditional home range methods, e.g., 90% utilization distribution (UD) (mean 2.29 ±2.71 km2) and 50% UD (mean 0.54 ±0.69 km2). Total residence area size increased significantly over the 8-year study, from <1 km2 before 2013 to ≥3 km2 in 2018 (R2 = 0.51, F1,14 = 14.55, p = 0.0019), corresponding to a period of decline in seagrass habitat and suggesting increased foraging effort. We identified three types of distinct use areas within residence areas where tracked turtles typically exhibited behavioral fidelity: foraging, resting, and cool weather refugia. These distinct use areas were smaller than high-use areas from previous studies; e.g., seagrass meadow foraging areas averaged 0.05 km2. Most turtles made daily transits between foraging and resting sites; for some individuals, these involved crossing frequently used vessel navigation channels. Seasonal variation in behavior suggested that the overwintering strategy for green turtles on the Bermuda Platform involves "optional dormancy," during which turtles spent less time on seagrass meadows and made brief excursions to distinct deeper habitats. Four individuals made directed (mean path straightness = 0.93 ±0.02 SD) developmental migrations away from Bermuda toward known adult foraging range. Results of our study further knowledge of the green turtle life cycle at a high-latitude site; they demonstrate that green turtles show fidelity to distinct use areas within developmental habitats over many years and exhibit seasonal movements.