A 'rich-get-richer' mechanism drives patchy dynamics and resistance evolution in antibiotic-treated bacteria.

Bacteria in nature often form surface-attached communities that initially comprise distinct subpopulations, or patches. For pathogens, these patches can form at infection sites, persist during antibiotic treatment, and develop into mature biofilms. Evidence suggests that patches can emerge due to heterogeneity in the growth environment and bacterial seeding, as well as cell-cell signaling. However, it is unclear how these factors contribute to patch formation and how patch formation might affect bacterial survival and evolution. Here, we demonstrate that a 'rich-get-richer' mechanism drives patch formation in bacteria exhibiting collective survival (CS) during antibiotic treatment. Modeling predicts that the seeding heterogeneity of these bacteria is amplified by local CS and global resource competition, leading to patch formation. Increasing the dose of a non-eradicating antibiotic treatment increases the degree of patchiness. Experimentally, we first demonstrated the mechanism using engineered Escherichia coli and then demonstrated its applicability to a pathogen, Pseudomonas aeruginosa. We further showed that the formation of P. aeruginosa patches promoted the evolution of antibiotic resistance. Our work provides new insights into population dynamics and resistance evolution during surface-attached bacterial growth.

Signaling Pathways Associated With Prior Cardiovascular Events in Hypertrophic Cardiomyopathy.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy. A subset of patients experience major adverse cardiovascular events (MACEs), including arrhythmias, strokes and heart failure. However, the molecular mechanisms underlying MACEs in HCM are still not well understood. Therefore, we conducted a multicenter case-control study of patients with HCM, comparing those with and without prior histories of MACEs to identify dysregulated signaling pathways through plasma proteomics profiling. METHODS: We performed plasma proteomics profiling of 4986 proteins. We developed a proteomics-based discrimination model in patients enrolled at 1 institution (training set) and externally validated the model in patients enrolled at another institution (test set). We performed pathway analysis of proteins dysregulated in patients with prior MACEs. RESULTS: A total of 402 patients were included, with 278 in the training set and 124 in the test set. In this cohort, 257 (64%) patients had prior MACEs (172 in the training set and 85 in the test set). Using the proteomics-based model from the training set, the area under the receiver operating characteristic curve was 0.82 (95% confidence interval, 0.75-0.90) in the test set. Patients with prior MACEs demonstrated dysregulation in pathways known to be associated with MACEs (eg, TGF-ß) and novel pathways (eg, Ras-MAPK and associated pathways). CONCLUSIONS: In this multicenter study of 402 patients with HCM, we identified both known and novel pathways dysregulated in a subset of patients with more advanced disease.

Modulation of microbial community dynamics by spatial partitioning.

Microbial communities inhabit spatial architectures that divide a global environment into isolated or semi-isolated local environments, which leads to the partitioning of a microbial community into a collection of local communities. Despite its ubiquity and great interest in related processes, how and to what extent spatial partitioning affects the structures and dynamics of microbial communities are poorly understood. Using modeling and quantitative experiments with simple and complex microbial communities, we demonstrate that spatial partitioning modulates the community dynamics by altering the local interaction types and global interaction strength. Partitioning promotes the persistence of populations with negative interactions but suppresses those with positive interactions. For a community consisting of populations with both positive and negative interactions, an intermediate level of partitioning maximizes the overall diversity of the community. Our results reveal a general mechanism underlying the maintenance of microbial diversity and have implications for natural and engineered communities.

Clinical trials of pharmacological interventions for SARS-CoV-2 published in leading medical journals report adherence but not how it was assessed.

AIMS: Adherence to pharmacological interventions in clinical trials is crucial for accurate identification of beneficial and adverse outcomes. The ways in which adherence to interventions should be reported in trial publications are described in the Template for Intervention Description and Replication (TIDieR), a 12-item extension of the Consolidated Standards of Reporting Trials reporting guidelines. The objective of this study was to assess compliance with TIDieR Items 11 and 12 of randomized controlled trials (RCTs) of interventions in SARS-CoV-2 infection published in 5 selected journals during 2021. METHODS: We assessed pharmacological interventions for SARS-CoV-2 infection reported in RCTs published in 2021 in the Annals of Internal Medicine, The BMJ, JAMA, The Lancet and The New England Journal for Medicine for compliance with TIDieR items addressing intervention adherence (Items 11 and 12). We calculated proportional adherence for pharmacological and comparator interventions where available. RESULTS: We found 75 eligible RCTs. Twenty-eight (37%) reported results of SARS-CoV-2 vaccinations. Compliance with Items 11 and 12 could be assessed in 71 of these 75. Of the 71 RCTs, 37 (52%) reported how adherence was assessed (Item 11), and 70 reported adherence rates (Item 12). Only 1 of the 71 RCTs (1.4%, 0-7.6%) fully complied with TIDieR Items 11 and 12. CONCLUSION: Half of RCTs of SARS-CoV-2 pharmacological interventions published in leading medical journals in 2021 complied with reporting of how adherence assessments were made and almost none complied with both TIDieR Items 11 and 12. The implications for interpretation, application and replication of findings based on these publications warrant consideration.

The effectiveness of psychoeducational interventions on caregiver-oriented outcomes in caregivers of adult cancer patients: A systematic review and meta-analysis.

OBJECTIVE: Cancer caregiving can result in increased psychosocial distress and poor health-related quality of life (QOL). Psychoeducation has been shown to be effective in enhancing caregiving-oriented outcomes. A systematic assessment of the overall effect of psychoeducational intervention (PEI) and identification of individual intervention characteristics that may contribute to the effectiveness of PEI is needed. METHODS: For this meta-analysis, relevant articles were identified through electronic databases using key search terms and their medical subject heading such as "family caregiver," "cancer," and "psychoeducational intervention." RESULTS: Twenty-eight controlled trials with 3876 participants were included. PEIs had beneficial effect on depression (Standardized Mean Difference [SMD] -0.26; 95% CI = -0.50 to -0.01, p < 0.04), anxiety (SMD -0.41; 95% CI = -0.82 to 0.01, p < 0.05), caregiver burden (SMD -0.84; 95% CI = -1.22 to -0.46, p < 0.0001) and QOL (SMD 0.59, 95% CI 0.24-0.93; p < 0.0009) at the immediate post-intervention period. At longer-term follow-up, the effectiveness of PEI was maintained on QOL (SMD 0.39, 95% CI = -0.00 to -0.77, p < 0.05), and anxiety (SMD -0.57; 95% CI = -1.09 to -0.06, p < 0.03). Moderation analysis showed that intervention characteristics such as studies conducted in high-income countries, group intervention and studies that focused on specific and mixed cancers explain some of the high variations observed among the included studies. CONCLUSIONS: PEI may benefit caregivers of cancer patients through the significant effects on caregiver burden, QOL, anxiety, and depression. The findings from the moderation analysis may be important for the design of future interventions.

Development and initial evaluation of a behavioural intervention to support weight management for people with serious mental illness: an uncontrolled feasibility and acceptability study.

BACKGROUND: The rates of obesity and associated health problems are higher in people with serious mental illness (SMI), such as schizophrenia and bipolar disorder, than the general population. A primary care referral to a behavioural weight management programme can be an effective intervention, but people with SMI have reported barriers to engaging with them and bespoke options are rarely provided in routine practice. It is possible that adjunct support addressing these specific barriers could help. Here we report the development, feasibility and acceptability of an intervention to improve uptake and engagement with a mainstream weight management programme for people with SMI. METHODS: We worked with people with a lived-experience of SMI and used the person-based approach to develop the 'Weight cHange for people with sErious mEntal iLlness' (WHEEL) intervention. It comprised a referral to a mainstream weight management programme (WW®) to be attended once a week, in-person or online, for 12-weeks. The adjunct support comprised a one-off, online consultation called Meet Your Mentor and weekly, telephone or email Mentor Check Ins for 12-weeks. We assessed the feasibility of WHEEL through the number of programme and adjunct support sessions that the participants attended. We analysed the acceptability of WHEEL using a thematic analysis of qualitative interviews conducted at baseline and at 12-week follow-up. Our exploratory outcome of clinical effectiveness was self-reported weight at baseline and at end-of-programme. RESULTS: Twenty participants were assessed for eligibility and 17 enrolled. All 17 participants attended Meet Your Mentor and one was lost to follow-up (94% retention). Nine out of 16 attended ≥50% of the weekly programme sessions and 12/16 attended ≥50% of the weekly check-ins. Participants reported in the interviews that the adjunct support helped to establish and maintain a therapeutic alliance. While some participants valued the in-person sessions, others reported that they preferred the online sessions because it removed a fear of social situations, which was a barrier for some participants. The mean change in self-reported weight was - 4·1 kg (SD: 3·2) at 12-weeks. CONCLUSIONS: A mainstream weight management programme augmented with brief and targeted education and low-intensity check-ins generated sufficient engagement and acceptability to warrant a future trial.

Smoking cessation for secondary prevention of cardiovascular disease.

BACKGROUND: Smoking is a leading cause of cardiovascular disease (CVD), particularly coronary heart disease (CHD). However, quitting smoking may prevent secondary CVD events in people already diagnosed with CHD.  OBJECTIVES: To examine the impact of smoking cessation on death from CVD and major adverse cardiovascular events (MACE), in people with incident CHD. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and the trials registries clinicaltrials.gov and the International Clinical Trials Registry Platform. We ran all searches from database inception to 15 April 2021.  SELECTION CRITERIA: We included cohort studies, and both cluster- and individually randomised controlled trials of at least six months' duration. We treated all included studies as cohort studies and analysed them by smoking status at follow-up. Eligible studies had to recruit adults (> 18 years) with diagnosed CHD and who smoked tobacco at diagnosis, and assess whether they quit or continued smoking during the study. Studies had to measure at least one of our included outcomes with at least six months' follow-up. Our primary outcomes were death from CVD and MACE. Secondary outcomes included all-cause mortality, non-fatal myocardial infarction, non-fatal stroke, new-onset angina and change in quality of life.  DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods for screening and data extraction.  We assessed the risk of bias for the primary outcomes using the ROBINS-I tool. We compared the incidence of death from CVD and of MACE (primary outcomes) between participants who quit smoking versus those who continued to smoke for each included study that reported these outcomes. We also assessed differences in all-cause mortality, incidence of non-fatal myocardial infarction, incidence of non-fatal stroke and new onset angina. We calculated hazard ratios (HRs) and 95% confidence intervals (95% CI). For our outcome, change in quality of life, we calculated the pooled standardised mean difference (SMD) and 95% CI for the difference in change in quality of life from baseline to follow-up between those who had quit smoking and those who had continued to smoke. For all meta-analyses we used a generic inverse variance random-effects model and quantified statistical heterogeneity using the I²statistic. We assessed the certainty of evidence for our primary outcomes using the eight GRADE considerations relevant to non-randomised studies. MAIN RESULTS: We included 68 studies, consisting of 80,702 participants. For both primary outcomes, smoking cessation was associated with a decreased risk compared with continuous smoking: CVD death (HR 0.61, 95% CI 0.49 to 0.75; I² = 62%; 18 studies, 17,982 participants; moderate-certainty evidence) and MACE (HR 0.57, 95% CI 0.45 to 0.71; I² = 84%; 15 studies, 20,290 participants; low-certainty evidence). These findings were robust to our planned sensitivity analyses. Through subgroup analysis, for example comparing adjusted versus non-adjusted estimates, we found no evidence of differences in the effect size. While there was substantial heterogeneity, this was primarily in magnitude rather than the direction of the effect estimates. Overall, we judged 11 (16%) studies to be at moderate risk of bias and 18 (26%) at serious risk, primarily due to possible confounding. There was also some evidence of funnel plot asymmetry for MACE outcomes. For these reasons, we rated our certainty in the estimates for CVD death as moderate and MACE as low.  For our secondary outcomes, smoking cessation was associated with a decreased risk in all-cause mortality (HR 0.60, 95% CI 0.55 to 0.66; I² = 58%; 48 studies, 59,354 participants), non-fatal myocardial infarction (HR 0.64, 95% CI 0.58 to 0.72; I² = 2%; 24 studies, 23,264 participants) and non-fatal stroke (HR 0.70, 95% CI 0.53 to 0.90; I² = 0%; 9 studies, 11,352 participants). As only one study reported new onset of angina, we did not conduct meta-analysis, but this study reported a lower risk in people who stopped smoking. Quitting smoking was not associated with a worsening of quality of life and suggested improvement in quality of life, with the lower bound of the CI also consistent with no difference (SMD 0.12, 95% CI 0.01 to 0.24; I² = 48%; 8 studies, 3182 participants).  AUTHORS' CONCLUSIONS: There is moderate-certainty evidence that smoking cessation is associated with a reduction of approximately one-third in the risk of recurrent cardiovascular disease in people who stop smoking at diagnosis. This association may be causal, based on the link between smoking cessation and restoration of endothelial and platelet function, where dysfunction of both can result in increased likelihood of CVD events.  Our results provide evidence that there is a decreased risk of secondary CVD events in those who quit smoking compared with those who continue, and that there is a suggested improvement in quality of life as a result of quitting smoking. Additional studies that account for confounding, such as use of secondary CVD prevention medication, would strengthen the evidence in this area.

Rate and Characteristics of Incompletely Excised Cutaneous Squamous Cell Carcinoma: A Dermatological Daily Practice Multicenter Prospective Cohort Study.

BACKGROUND: Incomplete excision of squamous cell carcinoma (cSCC) is associated with an increased risk of recurrence, metastasis, and mortality. OBJECTIVE: To determine the rate and characteristics of incompletely excised cSCC in a dermatological daily practice setting. METHODS: Prospective study of all patients who gave informed consent, with a cSCC treated with standard excision (SE) at 1 of 6 Departments of Dermatology in the Netherlands between 2015 and 2017. Pathological reports were screened to detect all incompletely excised cSCCs. RESULTS: A total of 592 patients with 679 cSCCs were included, whereby most cases were low risk cSCC (89%). The rate of incompletely excised cSCC was 4% ( n = 26), and the majority were high-risk cSCCs of which 24 invaded the deep excision margin. CONCLUSION: This prospective study showed that in a dermatological setting, the risk of an incompletely excised cSCC is low (4%) for a cohort that was dominated by low-risk cSCCs. Most incompletely excised cSCCs were of high risk, and incompleteness was almost always at the deep margins. These results suggest that for high-risk cSCC, one should pay attention especially to the deep margin when performing SE, and/or microscopic surgery should be considered.

The associations between lifestyle factors and mental well-being in baccalaureate nursing students: An observational study.

Lifestyle factors are modifiable habits that shape the way in which individuals live their lives and can influence mental health. This study examined the associations between lifestyle factors and mental well-being among baccalaureate nursing students at one Canadian university. A cross-sectional, observational online survey was distributed at one urban university campus in Ontario, Canada. Baccalaureate nursing students (n = 147) completed the survey containing questions for demographic variables, sleep quality, dietary pattern, alcohol use, physical activity, sitting time, cigarette smoking, depression, anxiety and stress. Linear regression analysis revealed that more sitting time, poor sleep quality, and low dairy consumption were associated with higher scores in depression, anxiety, and psychological stress. In conclusion, poor lifestyle behaviors such as sedentary lifestyle, poor sleep, and low dairy consumption may reduce the mental well-being of baccalaureate nursing students. Future efforts should aim to establish a causal relationship between lifestyle and mental well-being, which would contribute to the development of lifestyle interventions to promote mental health.

Exploring nursing engagement in providing virtual care to cancer patients in Canada.

As the world struggled with the COVID-19 pandemic, the provision of cancer care, along with all health services, moved more intentionally toward using virtual strategies. The implementation of virtual care had to happen quickly in an effort to provide safe care for individuals and avoid prolonged delays in patient care. Since then, the practice of virtual care and the involvement of oncology nurses in its delivery has evolved. However, there remains little evidence to guide oncology nurses in virtual care and establish best practices. A virtual workshop was held as part of the 2021 Annual Conference of the Canadian Association of Nurses in Oncology to explore the types of involvement oncology nurses have with virtual care, the barriers and facilitators of virtual care, and suggestions for the design of practice standards to guide oncology nurses in this arena of practice. This paper reports the findings of the workshop and shared implications for future priorities.

Association Between Immune Checkpoint Inhibitors With Cardiovascular Events and Atherosclerotic Plaque.

BACKGROUND: Immune checkpoint inhibitors (ICIs) treat an expanding range of cancers. Consistent basic data suggest that these same checkpoints are critical negative regulators of atherosclerosis. Therefore, our objectives were to test whether ICIs were associated with accelerated atherosclerosis and a higher risk of atherosclerosis-related cardiovascular events. METHODS: The study was situated in a single academic medical center. The primary analysis evaluated whether exposure to an ICI was associated with atherosclerotic cardiovascular events in 2842 patients and 2842 controls matched by age, a history of cardiovascular events, and cancer type. In a second design, a case-crossover analysis was performed with an at-risk period defined as the 2-year period after and the control period as the 2-year period before treatment. The primary outcome was a composite of atherosclerotic cardiovascular events (myocardial infarction, coronary revascularization, and ischemic stroke). Secondary outcomes included the individual components of the primary outcome. In addition, in an imaging substudy (n=40), the rate of atherosclerotic plaque progression was compared from before to after the ICI was started. All study measures and outcomes were blindly adjudicated. RESULTS: In the matched cohort study, there was a 3-fold higher risk for cardiovascular events after starting an ICI (hazard ratio, 3.3 [95% CI, 2.0-5.5]; P<0.001). There was a similar increase in each of the individual components of the primary outcome. In the case-crossover, there was also an increase in cardiovascular events from 1.37 to 6.55 per 100 person-years at 2 years (adjusted hazard ratio, 4.8 [95% CI, 3.5-6.5]; P<0.001). In the imaging study, the rate of progression of total aortic plaque volume was >3-fold higher with ICIs (from 2.1%/y before 6.7%/y after). This association between ICI use and increased atherosclerotic plaque progression was attenuated with concomitant use of statins or corticosteroids. CONCLUSIONS: Cardiovascular events were higher after initiation of ICIs, potentially mediated by accelerated progression of atherosclerosis. Optimization of cardiovascular risk factors and increased awareness of cardiovascular risk before, during, and after treatment should be considered among patients on an ICI.

CB1Rs in VMH neurons regulate glucose homeostasis but not body weight.

Cannabinoid 1 receptor (CB1R) inverse agonists reduce body weight and improve several parameters of glucose homeostasis. However, these drugs have also been associated with deleterious side effects. CB1R expression is widespread in the brain and in peripheral tissues, but whether specific sites of expression can mediate the beneficial metabolic effects of CB1R drugs, while avoiding the untoward side effects, remains unclear. Evidence suggests inverse agonists may act on key sites within the central nervous system to improve metabolism. The ventromedial hypothalamus (VMH) is a critical node regulating energy balance and glucose homeostasis. To determine the contributions of CB1Rs expressed in VMH neurons in regulating metabolic homeostasis, we generated mice lacking CB1Rs in the VMH. We found that the deletion of CB1Rs in the VMH did not affect body weight in chow- and high-fat diet-fed male and female mice. We also found that deletion of CB1Rs in the VMH did not alter weight loss responses induced by the CB1R inverse agonist SR141716. However, we did find that CB1Rs of the VMH regulate parameters of glucose homeostasis independent of body weight in diet-induced obese male mice.NEW & NOTEWORTHY Cannabinoid 1 receptors (CB1Rs) regulate metabolic homeostasis, and CB1R inverse agonists reduce body weight and improve parameters of glucose metabolism. However, the cell populations expressing CB1Rs that regulate metabolic homeostasis remain unclear. CB1Rs are highly expressed in the ventromedial hypothalamic nucleus (VMH), which is a crucial node that regulates metabolism. With CRISPR/Cas9, we generated mice lacking CB1Rs specifically in VMH neurons and found that CB1Rs in VMH neurons are essential for the regulation of glucose metabolism independent of body weight regulation.

Behavioral interventions for asthma self-management in South Asian populations: a systematic review.

OBJECTIVE: Asthma outcomes are significantly worse for minority groups, including South Asians (SAs), in high-income settings. Despite this, comparatively few existing studies have focused on SAs when studying the effectiveness of behavioral interventions on asthma self-management, and no prior study has synthesized these findings. We review the effectiveness of behavioral interventions on asthma management in adults and children of SA origin across low- (LICs), middle- (MICs), and high-income countries (HICs). METHODS: Data sources included EMBASE, MEDLINE, Cochrane Library and Trial registries: WHO, ICTRP and ClinicalTrials.gov. Eligibility criteria: randomized controlled trials (RCTs), quasi-RCTs and non-RCTs (controlled before-after [CBA] studies), published in English, with no publication year or country restrictions in adults and children of South Asian origin. Exclusion criteria: those focusing solely on pharmacological interventions. Search terms were "asthma" and "South Asian". RESULTS: We included 33 studies, 27 from MICs and 6 from HICs (education [n = 10], self-management plans [n = 6], yoga/breathing exercises [n = 10]) organizational interventions [n =1], diet therapy [n = 1] and combined interventions [n = 5]). Outcome measures included: blood biochemistry, lung function, healthcare utilization and quality of life. A meta-analysis was not performed due to significant study heterogeneity. CONCLUSION: Behavioral interventions for asthma management in SAs are effective. Educational interventions that aim to optimize asthma knowledge, control, and inhaler technique, and yoga/breathing exercises are most effective for improved long-term outcomes in adults and children across LICs and MICs. Further research is needed to evaluate the effectiveness of all behavioral interventions for SAs in HICs to better inform current guidance by policy makers and health care providers.

Interventions to improve vitamin D status in at-risk ethnic groups during pregnancy and early childhood: a systematic review.

OBJECTIVE: To systematically review the literature with the primary aim of identifying behavioural interventions to improve vitamin D stores in children from at-risk ethnic groups. DESIGN: Review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PROSPERO registration number: CRD42017080932. Health Behaviour Model and Behaviour Change Wheel framework constructs used to underpin evaluation of interventions. Methodological quality evaluated using Cochrane Risk of Bias, Cochrane ROBINS-I and NHLBI tools. SETTING: Databases Cochrane Library, MEDLINE, EMBASE, CINAHL with secondary search of Google Scholar. No country limits set. Papers between January 1990 and February 2018, published in English included. Anticipating study heterogeneity, outcome measures not pre-specified and identified from individual full papers. Updated literature search November 2020. PARTICIPANTS: Patient or population including pregnant women, newborns and children aged under 18 years, from Asian or African ethnic groups. RESULTS: Of 10 690 articles screened, 298 underwent full-text review, with 24 ultimately included for data extraction. All identified studies conducted a vitamin D pharmacological supplementation intervention, with two also incorporating a behavioural intervention strategy. No study explicitly defined a primary aim of evaluating a behavioural intervention, undertaken to study its effect on vitamin D supplement uptake. CONCLUSIONS: There is a need to address the paucity of data in ethnic at-risk children on how behavioural interventions ideally developed and co-produced with the community under study, affect and help improve vitamin D uptake, within the antenatal and pregnancy phase as well as during childhood.

Cultural contexts during a pandemic: a qualitative description of cultural factors that shape protective behaviours in the Chinese-Canadian community.

BACKGROUND: During the COVID-19 pandemic, there have been significant variations in the level of adoption of public health recommendations across international jurisdictions and between cultural groups. Such variations have contributed to the dissimilar levels of risks associated with this world-changing viral infection and have highlighted the potential role of culture in assigning meaning and importance to personal protective behaviours. The purpose of this study is to describe the cultural factors during the COVID-19 pandemic that shaped protective health behaviours in the Chinese-Canadian community, one of the largest Chinese diasporas outside of Asia. METHODS: A qualitative descriptive design was employed. Content analysis was used to analyze the data from semi-structured virtual interviews conducted with 83 adult Chinese-Canadian participants residing in a metropolitan area in the Province of Ontario, Canada. FINDINGS: The cultural factors of collectivism, information seeking behaviour, symbolism of masks, and previous experience with severe acute respiratory syndrome (SARS) emerged as themes driving the early adoption of personal protective behaviours within the Chinese-Canadian community during the first wave of COVID-19. These protective behaviours that emerged prior to the first nation-wide lockdown in Canada included physical distancing, mask use, and self-quarantine beyond what was required at the time. CONCLUSION: These findings have implications for the development of future public health interventions and campaigns targeting personal protective behaviours in this population and other ethnic minority populations with similar characteristics.

The Effect of High-Fidelity, Interprofessional Simulation on Teamwork Skills and Attitudes Toward Interprofessional Education.

ABSTRACT: High-fidelity simulation is increasingly popular in interprofessional education (IPE). This study aimed to determine the effectiveness of high-fidelity simulation in teaching IPE content to prelicensure trainees. A quasi-experimental study took place at a simulation center in Southern California. It assessed medical and nursing students' teamwork skills and attitudes toward IPE before and after high-fidelity simulation. Multivariate analysis of variance results revealed a decline in positive attitudes toward IPE postintervention in both medical and nursing students. No changes in teamwork skills and no differences between nursing and medical trainees were found. The implications of the study's findings are discussed.

Evaluation of an intervention to provide brief support and personalized feedback on food shopping to reduce saturated fat intake (PC-SHOP): A randomized controlled trial.

BACKGROUND: Guidelines recommend reducing saturated fat (SFA) intake to decrease cardiovascular disease (CVD) risk, but there is limited evidence on scalable and effective approaches to change dietary intake, given the large proportion of the population exceeding SFA recommendations. We aimed to develop a system to provide monthly personalized feedback and healthier swaps based on nutritional analysis of loyalty card data from the largest United Kingdom grocery store together with brief advice and support from a healthcare professional (HCP) in the primary care practice. Following a hybrid effectiveness-feasibility design, we tested the effects of the intervention on SFA intake and low-density lipoprotein (LDL) cholesterol as well as the feasibility and acceptability of providing nutritional advice using loyalty card data. METHODS AND FINDINGS: The Primary Care Shopping Intervention for Cardiovascular Disease Prevention (PC-SHOP) study is a parallel randomized controlled trial with a 3 month follow-up conducted between 21 March 2018 to 16 January2019. Adults ≥18 years with LDL cholesterol >3 mmol/L (n = 113) were recruited from general practitioner (GP) practices in Oxfordshire and randomly allocated to "Brief Support" (BS, n = 48), "Brief Support + Shopping Feedback" (SF, n = 48) or "Control" (n = 17). BS consisted of a 10-minute consultation with an HCP to motivate participants to reduce their SFA intake. Shopping feedback comprised a personalized report on the SFA content of grocery purchases and suggestions for lower SFA swaps. The primary outcome was the between-group difference in change in SFA intake (% total energy intake) at 3 months adjusted for baseline SFA and GP practice using intention-to-treat analysis. Secondary outcomes included %SFA in purchases, LDL cholesterol, and feasibility outcomes. The trial was powered to detect an absolute reduction in SFA of 3% (SD3). Neither participants nor the study team were blinded to group allocation. A total of 106 (94%) participants completed the study: 68% women, 95% white ethnicity, average age 62.4 years (SD 10.8), body mass index (BMI) 27.1 kg/m2 (SD 4.7). There were small decreases in SFA intake at 3 months: control = -0.1% (95% CI -1.8 to 1.7), BS = -0.7% (95% CI -1.8 to 0.3), SF = -0.9% (95% CI -2.0 to 0.2); but no evidence of a significant effect of either intervention compared with control (difference adjusted for GP practice and baseline: BS versus control = -0.33% [95% CI -2.11 to 1.44], p = 0.709; SF versus control = -0.11% [95% CI -1.92 to 1.69], p = 0.901). There were similar trends in %SFA based on supermarket purchases: control = -0.5% (95% CI -2.3 to 1.2), BS = -1.3% (95% CI -2.3 to -0.3), SF = -1.5% (95% CI -2.5 to -0.5) from baseline to follow-up, but these were not significantly different: BS versus control p = 0.379; SF versus control p = 0.411. There were small reductions in LDL from baseline to follow-up (control = -0.14 mmol/L [95% CI -0.48, 0.19), BS: -0.39 mmol/L [95% CI -0.59, -0.19], SF: -0.14 mmol/L [95% CI -0.34, 0.07]), but these were not significantly different: BS versus control p = 0.338; SF versus control p = 0.790. Limitations of this study include the small sample of participants recruited, which limits the power to detect smaller differences, and the low response rate (3%), which may limit the generalisability of these findings. CONCLUSIONS: In this study, we have shown it is feasible to deliver brief advice in primary care to encourage reductions in SFA intake and to provide personalized advice to encourage healthier choices using supermarket loyalty card data. There was no evidence of large reductions in SFA, but we are unable to exclude more modest benefits. The feasibility, acceptability, and scalability of these interventions suggest they have potential to encourage small changes in diet, which could be beneficial at the population level. TRIAL REGISTRATION: ISRCTN14279335.

Disturbances Can Promote and Hinder Coexistence of Competitors in Ongoing Partner Choice Mutualisms.

Ecosystems are under threat from anthropogenic and natural disturbances, yet little is known about how these disturbances alter mutualistic interactions. Many mutualistic interactions are highly context dependent and dynamic due to "ongoing" partner choice, impeding our understanding of how disturbances might influence mutualistic systems. Previously we showed that in the absence of additional known mechanisms of competitive coexistence, mutualistic fungi can coexist in a system where the plant community associates dynamically with two empirically defined arbuscular mycorrhizal fungal types: a cheap kind that provides low nutrient benefits, and an expensive type that provides high nutrient benefits. We built on this framework to ask how disturbances of different types, frequencies, amplitudes, and predictabilities alter ongoing partner choice and thereby influence the coexistence of mutualists. We found that the effects of disturbances depend on the type, amplitude, and predictability of disturbances and, to a lesser extent, on their frequency. Disturbance can disrupt mutualist coexistence by enabling hosts more efficiently to exclude partners that behave as parasites. Disturbance can also promote coexistence by altering the strength and direction of consumer-resource interactions. Predicting the effects of disturbance on the mutualist community therefore requires us to understand better the consumer-resource relationships under various environmental conditions. We show how, through such context-dependent effects, disturbance and ongoing partner choice can together generate relative nonlinearity and investment in future benefit, introducing fluctuation-dependent mechanisms of competitive coexistence. Our findings support a broadening of the conceptual framework regarding disturbances and competition to include fluctuation-dependent mechanisms alongside the spatiotemporal intermediate disturbance hypothesis.

The association among cancer patients' collaboration with their healthcare providers, self-management and well-being during radiotherapy: An observational, cross-sectional survey.

OBJECTIVES: Patients adapt to cancer through self-management, which requires collaboration between patients and their healthcare providers. We aimed to describe patterns of patient-provider collaboration during radiotherapy and examine associations among patient-provider collaboration, self-management and well-being. METHODS: An observational, cross-sectional study was conducted at a cancer centre in the province of Ontario, Canada. Cancer patients (N = 130) completed a one-time questionnaire during their radiotherapy. The questionnaire assessed three variables: collaboration with healthcare providers, self-management and well-being. Patterns of collaboration were analysed using descriptive statistics. Associations among study variables were assessed through structural equation modelling (SEM). Separate models were tested for patient-nurse and patient-oncologist collaboration. RESULTS: Participants reported greater collaboration with oncologists than with nurses or radiation therapists. Most participants reported no collaboration with other providers within healthcare teams (e.g. social workers, dietitians). SEM revealed different patterns for the patient-nurse and patient-oncologist collaboration models, where collaboration predicted one self-management aspect, and both physical and mental well-being. CONCLUSION: During radiotherapy, patients collaborated mainly with doctors, nurses and radiation therapists. Collaborative relationships between patients and providers may enhance patient outcomes by fostering their self-management skills. Initiatives to strengthen patient-provider relationships and support self-management should be developed and applied to interprofessional-cancer-care teams. IMPACT: This is the first known study to empirically support the links among patient-provider collaboration, self-management and patient outcomes. The study results can enhance practice, research and education.

Dermatofibrosarcoma Protuberans Re-excision and Recurrence Rates in the Netherlands Between 1989 and 2016.

Dermatofibrosarcoma protuberans is a rare soft tissue tumour with a very low (p < 0.5%) rate of metastasis. Rates of re-excision and recurrence were determined using data from the Netherlands Cancer Registry between 1989 and 2016. Of the 1,890 instances of dermatofibrosarcoma protuberans included, 87% were treated with excision, 4% with Mohs micrographic surgery, and 9% otherwise or unknown. Linked pathology data were retrieved for 1,677 patients. Half of all excisions (847/1,644) were incomplete and 29% (192/622) of all re-excisions were incomplete. The cumulative incidence of a recurrence was 7% (95% confidence interval (95% CI) 6-8) during a median follow-up of 11 years (interquartile range (IQR) 6-17). After Mohs micrographic surgery (n = 34), there were no recurrences during a median follow-up of 4 years (IQR 3-6). Due to the high rate of incomplete excisions and recurrences after excision, this study supports the European guideline, which recommends treating dermatofibrosarcoma protuberans with Mohs micrographic surgery in order to decrease the rate of recurrence.