A randomised Phase II trial of carboplatin and gemcitabine ± vandetanib in first-line treatment of patients with advanced urothelial cell cancer not suitable to receive cisplatin.

OBJECTIVES: To assess the efficacy and tolerability of the dual epidermal growth factor receptor/vascular endothelial growth factor receptor inhibitor, vandetanib, in combination with carboplatin and gemcitabine in the first-line treatment of patients with advanced transitional cell carcinoma urothelial cancer (UC) who were unsuitable for cisplatin. PATIENTS AND METHODS: From 2011 to 2014, 82 patients were randomised from 16 hospitals across the UK into the TOUCAN double-blind, placebo-controlled randomised Phase II trial, receiving six 21-day cycles of intravenous carboplatin (target area under the concentration versus time curve 4.5, day 1) and gemcitabine (1000 mg/m2 days 1 and 8) combined with either oral vandetanib 100 mg or placebo (once daily). Progression-free survival (PFS; primary endpoint), adverse events, tolerability and feasibility of use, objective response rate and overall survival (OS) were evaluated. Intention-to-treat and per-protocol analyses were used to analyse the primary endpoint. RESULTS: The 82 patients were randomised 1:1 to vandetanib (n = 40) or placebo (n = 42), and 25 patients (30%) completed six cycles of all allocated treatment. Toxicity Grade ≥3 was experienced in 80% (n = 32) and 76% (n = 32) of patients in the vandetanib and placebo arms, respectively. The median PFS was 6.8 and 8.8 months for the vandetanib and placebo arms, respectively (hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.65-1.76; P = 0.71); the median OS was 10.8 vs 13.8 months (HR 1.41, 95% CI 0.79-2.52; P = 0.88); and radiological response rates were 50% and 55%. CONCLUSION: There is no evidence that vandetanib improves clinical outcome in this setting. Our present data do not support its adoption as the regimen of choice for first-line treatment in patients with UC who were unfit for cisplatin.

Access to principal treatment centres and survival rates for children and young people with cancer in Yorkshire, UK.

BACKGROUND: Principal Treatment Centres (PTC) were established to provide age-appropriate care as well as clinical expertise for children and young people with cancer. However, little is known about the effects of specialist treatment centres on survival outcomes especially for teenagers and young adults. This population-based study aimed to describe access to PTC and the associated trends in survival for 0-24 year olds accounting for stage of disease at presentation and treatment. METHODS: Patients diagnosed from 1998-2009 aged 0-24 years were extracted from the Yorkshire Specialist Register of Cancer in Children and Young People, including information on all treating hospitals, followed-up until 31st December 2014. The six commonest cancer types were included: leukaemia (n = 684), lymphoma (n = 558), CNS tumours (n = 547), germ cell tumours (n = 364), soft tissue sarcomas (n = 171) and bone tumours (n = 163). Treatment was categorised into three groups: 'all', 'some' or 'no' treatment received at a PTC. Treatment at PTC was examined by diagnostic group and patient characteristics. Overall survival was modelled using Cox regression adjusting for case-mix including stage, treatment and other socio-demographic and clinical characteristics. RESULTS: Overall 72% of patients received all their treatment at PTC whilst 13% had no treatment at PTC. This differed by diagnostic group and age at diagnosis. Leukaemia patients who received no treatment at PTC had an increased risk of death which was partially explained by differences in patient case-mix (adjusted Hazard Ratio (HR) = 1.73 (95%CI 0.98-3.04)). Soft tissue sarcoma patients who had some or no treatment at PTC had better survival outcomes, which remained after adjustment for patient case-mix (adjusted HR = 0.48 (95%CI 0.23-0.99)). There were no significant differences in outcomes for other diagnostic groups (lymphoma, CNS tumours, bone tumours and germ cell tumours). For leukaemia patients survival outcomes for low risk patients receiving no treatment at PTC were similar to high risk patients who received all treatment at PTC, implying a benefit for care at the PTC. CONCLUSION: This study demonstrates that for leukaemia patients receiving treatment at a PTC is associated with improved survival that may compensate for a poorer prognosis presentation. However, further information on risk factors is needed for all diagnostic groups in order to fully account for differences in patient case-mix.

Experiences of healthcare team members involved in facial transplant surgery and patient care.

BACKGROUND: Situations that highlight the healthcare team member vulnerability, present ethically laden questions, or are innovative in nature may have a long-term personal and professional impact on caregivers and, consequently, directly or indirectly affect patient care. The ethical experiences and perceptions of the healthcare team members involved in facial transplantation procedures and patient care have not been explored. OBJECTIVE: The objective of this study was to explore healthcare team member experiences of caring for facial transplantation patients, using an ethical framework. METHODS: This study used a qualitative descriptive design to explore the experiences of 26 multidisciplinary healthcare team members, including professional, ancillary, and support staff who have participated in facial transplantation procedures and patient care. Individual, private, semistructured interviews were conducted. RESULTS: Two main themes emerged: individual sense of purpose and esprit de corps. Individual sense of purpose describes the meaning of the experience that involvement in facial transplantation had for the participants and comprises three subthemes: "getting it right, "transforming a life," and "spirituality." The theme esprit de corps conveys the morale of the healthcare team members involved in facial transplantation and was expressed through three subthemes: "leadership," "teamwork," and "environment." DISCUSSION: Many potential ethical dilemmas were mitigated by an overwhelming sense of moral obligation to help patients with complex cosmetic, functional, and mechanical facial deficits. Participants in this study unanimously believed that the risk-benefit ratio of the procedure and subsequent treatment supported its implementation.

Sleep hygiene program implementation in patients with traumatic brain injury.

PURPOSE: Traumatic brain injury (TBI) is a serious public health problem. The impact of TBI on the individual is multifaceted and includes neurocognitive, behavioral, and psychiatric disturbances as well as greater predisposition for dementia. A common but significant problem reported by patients after TBI is sleep disturbance. The purpose of this manuscript is twofold: (1) to describe our experience with implementation of the newly developed sleep hygiene guidelines; and (2) to report our preliminary results of implementation of the sleep hygiene guidelines on TBI patient outcomes. METHODS: A mixed methods approach was used to assess implementation of sleep hygiene guidelines and to gather preliminary data on outcomes. RESULTS: Although not statistically significant, the average self-reported sleep duration of these TBI patients was slightly higher in 2010 than 2009, with a FIM score that was similar for both time points. In 2009, the mean change in functional independence measure (FIM) score (n = 34) was 1.44. In 2010, the mean change in FIM score (n = 33) was 1.42. In 2009, most patients (n = 13) admitted to the hospital continued to take medications and were discharged with a sleep aid. In 2010, most patients reported a change in their sleep medication prescriptions (on medications at admission and none at discharge) or had continued to take their prescribed sleep medications from admission to discharge (n = 12). CONCLUSION: Sleep disorders have a major impact on health outcomes in patients with TBI. To optimize rehabilitation and ultimately improve functional outcomes of patients with TBI, implementation of evidence-based clinical guidelines for sleep is imperative. We report our initial experience with implementation of sleep guidelines.

Leadership in Nursing Education for Advancing a School of Nursing-Led Center for Climate Change, Climate Justice, and Health.

BACKGROUND: This article examines innovations in the development and advancement of a school of nursing-led climate change center and innovative leadership related to climate change and health in nursing education. METHOD: The integration of health consequences of climate change in curricula and continuing education is essential to prepare nursing students and nurses for clinical practice. RESULTS: Transformational leadership is a key concept for effective leadership in nursing education to address climate change as the looming public health challenge of the 21st century. Transformational leadership strengthened one nursing program's curricula, dissemination of relevant scholarship, and achievements with public health outreach related to climate change, climate justice, and health. CONCLUSION: Nursing education leaders can influence nursing practice and improve societal health outcomes related to the health consequences of climate change across all levels of education and continuing education for professional nurses. [J Nurs Educ. 2023;62(9):528-531.].

Health Consequences of Climate Change: Continuing Education Opportunities for Health Professionals in the United States.

Climate change is a looming public health challenge. The health consequences of climate change are increasingly recognized as contributing to negative health outcomes for individuals, families, communities, and populations. The education of health professionals in academic programs and continuing education in clinical practice settings is critical in today's world. The Association of American Medical Colleges and the National League for Nursing, among other organizations, have urged academic programs to include the impact of climate change on health in health professions education and have started to integrate it into curricula. However, health professionals educated over the past several decades have received little content related to the deleterious impact of climate change on health. Therefore, continuing education programs addressing the health consequences of climate change are being developed to fill the gap in health professions education globally. This review study explicated the available continuing education opportunities for public health professionals and health care providers related to the health consequences of climate change. [J Contin Educ Nurs. 2023;54(12):561-566.].

The nurse practitioner's role in addressing chronic sequelae of Lyme disease as a climate change related disease.

ABSTRACT: A major health consequence of climate change is an increased prevalence of vector-borne diseases due to changes in temperatures and the environments in which vectors can survive and carry out transmissible activity. Because of climate change, emerging health challenges related to the warming of the planet have led to an increase in vector-borne diseases in broadening geographic areas. Individuals affected with Lyme disease may present with a variety of symptoms, which highlights the importance of illness recognition to ensure that a patient can receive timely treatment and effective support. Despite the focus on early detection and treatment of acute Lyme disease, chronic health problems associated with Lyme disease are an emerging problem in the 21st century. This article focuses on the role of nurse practitioners and members of the health professional team in the recognition, clinical care, patient education, and management of increasing rates of chronic Lyme disease.

A historical, clinical, and ethical overview of the emerging science of facial transplantation.

In the past 5 years, a total of 16 facial transplantation surgeries have been performed in France, China, Spain, and the United States. Facial transplantation has become a surgical option in clinical situations in which soft tissue and bone loss is accompanied by severe cosmetic, sensory, and functional deficiencies due to disease, trauma, or congenital malformations. With the introduction of facial tissue transplantation surgery came complex clinical, technological, and ethical patient care issues. These complex issues included determining patient selection criteria, refining donor tissue procurement techniques, predicting expected functional outcomes, appreciating the limitations of obtaining a fully informed consent for an innovative procedure, and deliberating the immunological response and postoperative immunosuppressant requirements of the recipient. In addition, psychological implications for the patient, societal consequences, and ethical concerns have been discussed. The short-term results have been positive. Results to date indicate that the clinical, technical, and immunological patient care issues in this emerging science appear to mirror those of other reconstructive and organ transplantation procedures. The long-term physical, emotional, and psychological effects on the recipient patient, as well as long-term consequences to the donor's family, are yet to be validated.

Isotope dilution quantification of ultratrace gamma-glutamyl-Se-methylselenocysteine species using HPLC with enhanced ICP-MS detection by ultrasonic nebulisation or carbon-loaded plasma.

A method for the accurate determination of ultratrace selenium species of relevance to cancer research, such as gamma-glutamyl-Se-methylselenocysteine (gamma-glutamyl-SeMC), using species-specific double isotope dilution analysis (IDA) with HPLC-ICP-MS is reported for the first time. The (77)Se-enriched gamma-glutamyl-SeMC spike was produced in-house by collecting the fraction at the retention time of the gamma-glutamyl-SeMC peak from a chromatographed aqueous extract of (77)Se-enriched yeast, pooling the collected fractions and freeze-drying the homogenate. The Se content of this spike was characterised using reverse isotope dilution mass spectrometry (IDMS) and the isotopic composition of this spike was checked prior to quantification of the natural abundance dipeptide species in garlic using speciated IDA. The extraction of the gamma-glutamyl-SeMC species in water was performed in a sonication bath for 2 h after adding an appropriate quantity of (77)Se-enriched gamma-glutamyl-SeMC to 50 mg of garlic to give optimal (78)Se/(77)Se and (82)Se/(77)Se ratios of 1.5 and 0.6, respectively. The effect of ultrasonic nebulisation, in comparison with the loading of the ICP with carbon (through the addition of methane gas on-line), on the detection of Se associated with gamma-glutamyl-SeMC using collision/reaction cell ICP-MS with hydrogen as collision gas was investigated. Sensitivity enhancements of approximately fourfold and twofold were achieved using USN and methane mixed plasma, respectively, in comparison with conventional nebulisation and conventional Ar ICP-MS. However, an approximately twofold improvement in the detection limit was achieved using both approaches (42 ng kg(-1) for (78)Se using peak height measurements). The use of species-specific IDMS enabled quantification of the dipeptide species at ng g(-1) levels (603 ng g(-1) Se) in the complex food matrix with a relative standard deviation (RSD, n = 4) of 4.5%, which was approximately half that obtained using standard addition as a confirmatory technique. Furthermore, good agreement was found between the gamma-glutamyl-SeMC species concentrations obtained using both calibration methods.

Feasibility of family member presence in the OR during breast biopsy procedures.

Family-centered care is an accepted and promoted philosophy within the health care community. Perioperative nurses are empowered to support change in the health care arena and to examine and institute policies that affect patient care. This study examined the feasibility of family presence in the OR during breast biopsy procedures performed with local anesthesia, by ascertaining perioperative nurses' attitudes toward the concept. Family presence in the OR during breast biopsy procedures is considered a novel initiative. The results of this study indicate that the feasibility of instituting this intervention would be challenged by system barriers.

Ebola Emergency Preparedness: Simulation Training for Frontline Health Care Professionals.

INTRODUCTION: At Brigham and Women's Hospital, we identified the need for a comprehensive training program designed to prepare frontline staff to safely manage a patient with Ebola viral disease (EVD). The primary goal of this program was to ensure the safety of staff, patients, and the general public by training staff in the correct use of personal protective equipment (PPE) before, during, and after care of patients with EVD. METHODS: We delivered a 4-hour experiential training program to frontline health care professionals who would be expected to care for a patient with EVD. The program occurred in a simulation center with multiple flexible spaces and consisted of demonstration, multiple skills practice sessions, and a patient simulation case. We analyzed completed pre- and posttraining questionnaires. The questionnaire assessed their subjective level of confidence in three key areas: donning and doffing PPE, performing clinical skills while wearing PPE, and management of a contamination breach. RESULTS: This program was effectively deployed in the STRATUS Center for Medical Simulation over a 4-month period, with 220 health care professionals participating in the training and 195 participants completing the pre-/posttraining questionnaires. Our intervention significantly increased the confidence of participants on each primary objective (p = .001 for all three stations). DISCUSSION: This interprofessional simulation-based program has been shown to be a well-received method of training clinicians to manage patients collaboratively during an EVD outbreak. Our intent is that the skills taught in this training program would also be transferable to management of other infectious diseases in the clinical setting.

Non-Hodgkin lymphoma.

Non-Hodgkin lymphoma is a non-specific term that includes several lymphoproliferative malignant diseases with different clinical and histological appearances. Here, we concentrate on adult lymphomas. We look at their molecular basis, at the development of a classification system based on a better understanding of the biology of the various subgroups, and at how refinement of adverse prognostic factor groupings helps in clinical management. Lymphomas can present in various ways and be difficult to diagnose. About a quarter of cases arise extranodally and might present special problems. Developments in cytotoxic chemotherapy have led to good long-term survival prospects for aggressive lymphoma; introduction of novel approaches, including monoclonal antibody therapy, offers promise for indolent lymphoma, and should further improve prognosis for aggressive tumours.

Age- and education-adjusted normative data for the Montreal Cognitive Assessment (MoCA) in older adults age 70-99.

The original validation study for the Montreal Cognitive Assessment (MoCA) suggests a cutoff score of 26; however, this may be too stringent for older adults, particularly for those with less education. Given the rapidly increasing number of older adults and associated risk of dementia, this study aims to provide appropriate age- and education-adjusted norms for the MoCA. Data from 205 participants in an ongoing longevity study were used to derive normative data. Individuals were grouped based on age (70-79, 80-89, 90-99) and education level (≤12 Years, 13-15, ≥16 Years). There were significant differences between age and education groups with younger and more educated participants outperforming their counterparts. Forty-six percent of our sample scored below the suggested cutoff of 26. These normative data may provide a more accurate representation of MoCA performance in older adults for specific age and education stratifications.

Peripheral neuropathy in HIV: an analysis of evidence-based approaches.

Peripheral neuropathy is a common and vexing symptom for people living with HIV infection (PLWH). Neuropathy occurs in several different syndromes and is identified in the literature as distal sensory polyneuropathy or distal sensory peripheral neuropathy. More recently, the HIV literature has focused on the syndrome as painful HIV-associated sensory neuropathy, addressing the symptom rather than the underlying pathophysiology. Assessment of neuropathy in PLWH is critical and must be incorporated into nursing practice for each visit. Neuropathy has been attributed to the direct effects of HIV, exposure to antiretroviral medications (particularly the nucleoside reverse transcriptase inhibitors), advanced immune suppression, and comorbid tuberculosis infection and exposure to antituberculosis medications. Evidence supports the importance of addressing neuropathy in PLWH with pharmacologic treatment regimens and complementary/alternative approaches. This paper examines the pathophysiology, evidence, and approaches to managing peripheral neuropathy. A case study has been included to illustrate a patient's experience with neuropathy symptoms.

A pilot study examining food insecurity and HIV risk behaviors among individuals recently released from prison.

Annually 700,000 individuals are released from U.S. prison, many at risk for food insecurity and HIV. The association between food insecurity and HIV risk behaviors has been established but not in this population. To investigate this association, we recruited 110 recently released prisoners to participate in a survey. Ninety-one percent of our sample was food insecure; 37% did not eat for an entire day in the past month. Those who did not eat for an entire day were more likely to report using alcohol, heroin, or cocaine before sex or exchanging sex for money compared to those who had at least a meal each day. From this pilot study, released prisoners appear to be at risk for food insecurity, and not eating for an entire day is associated with certain HIV risk behaviors. HIV prevention efforts should include longitudinal studies on the relationship between food insecurity and HIV risk behaviors among recently released prisoners.

The relationship of the emotional climate of work and threat to patient outcome in a high-volume thoracic surgery operating room team.

CONTEXT: It is widely believed that the emotional climate of surgical team's work may affect patient outcome. OBJECTIVE: To analyse the relationship between the emotional climate of work and indices of threat to patient outcome. DESIGN: Interventional study. SETTING: Operating rooms in a high-volume thoracic surgery centre from September 2007 to June 2008. PARTICIPANTS: Thoracic surgery operating room teams. INTERVENTION: Two 90 min team-skills training sessions focused on findings from a standardised safety-culture survey administered to all participants and highlighting positive and problematic aspects of team skills, communication and leadership. MAIN OUTCOME MEASURES: Relationship of functional or less functional emotional climates of work to indices of threat to patient outcome. RESULTS: A less functional emotional climate corresponded to more threat to outcome in the sterile surgical environment in the pre-intervention period (p<0.05), but not in the post-intervention or sustaining period of this study. This relationship did not exist in the anaesthesia or circulating environments of the operating room. CONCLUSIONS: The emotional climate of work in the sterile surgical environment appeared to be related to threat to patient outcome prior to, but not after, a team-training intervention. Further study of the relationship between the emotional climate of work and threat to patient outcome using reproducible methods is required.

Representational signalling in birds.

Some animals give specific calls when they discover food or detect a particular type of predator. Companions respond with food-searching behaviour or by adopting appropriate escape responses. These signals thus seem to denote objects in the environment, but this specific mechanism has only been demonstrated for monkey alarm calls. We manipulated whether fowl (Gallus gallus) had recently found a small quantity of preferred food and then tested for a specific interaction between this event and their subsequent response to playback of food calls. In one treatment, food calls thus potentially provided information about the immediate environment, while in the other the putative message was redundant with individual experience. Food calls evoked substrate searching, but only if the hens had not recently discovered food. An identical manipulation had no effect on responses to an acoustically matched control call. These results show that chicken food calls are representational signals: they stimulate retrieval of information about a class of external events. This is the first such demonstration for any non-primate species. Representational signalling is hence more taxonomically widespread than has previously been thought, suggesting that it may be the product of common social factors, rather than an attribute of a particular phylogenetic lineage.