Implementation of an Extubation Readiness Guideline for Preterm Infants.

BACKGROUND: Intubated preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV neonatal intensive care unit (NICU) faced a high number of ventilator days. Based on 6 weeks of electronic health record (EHR) chart audits of extubations in this NICU in 2021, 44% of preterm infants 32 6 / 7 weeks or less of gestation were intubated for more than 28 days, with an average of 23 days on a ventilator. This NICU lacked a standardized extubation guideline providing criteria to drive extubation eligibility. PURPOSE: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an extubation readiness guideline in preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV NICU. METHODS: This project occurred over a 17-week period in 2021. Implementation included a multidisciplinary committee formation, identification of champions, NICU staff education, completion of a guideline checklist by bedside nursing (for eligible patients), clinician reminders, and chart audits for collection of pre-/postimplementation data. Staff education completion, guideline use and compliance, demographic patient data, ventilator days, time to first extubation, and need for reintubation were tracked. RESULTS: Postimplementation data indicated decreased need for intubation for more than 28 days, ventilator days, and days to first extubation attempt. IMPLICATIONS FOR PRACTICE AND RESEARCH: Results suggested that implementation of the evidence-based guideline was effective in decreasing average total ventilator days for preterm infants 32 6 / 7 weeks or less of gestation.

Improving Safe Infant Sleep Compliance Through Implementation of a Safe Sleep Bundle.

BACKGROUND: Sleep-related infant deaths continue to be a significant public health issue that nondiscriminately impacts family units with increased risk notably in premature infants discharged home from the neonatal intensive care unit (NICU). The American Academy of Pediatrics endorses the use of safe sleep practices with specific recognition of the unique challenges faced in the NICU setting. PURPOSE: The purpose of this quality improvement (QI) project was to implement a safe sleep bundle and evaluate its effectiveness in improving caregiver compliance to safe sleep practices in a level III NICU at a large joint military medical facility. METHODS: A QI initiative with a pre- and postanalysis was performed using a convenience method of sampling. Infants 32 weeks or more post-menstrual age in a level III NICU were analyzed pre- and post-interventions. The intervention included a safe sleep bundle that encompassed: (1) policy update, (2) standardized sleep sacks, (3) crib cards and certificates, and (4) creation of a provider order set in the electronic health record (EHR). A standardized crib audit tool evaluated sleep and bed position, items in the crib, order set in the EHR with consideration of special medical circumstances. RESULTS: Postintervention assessment after the implementation resulted in a significant improvement of overall safe sleep compliance modeled by NICU staff, increasing to 100% from a baseline of 18% pre-intervention (P = .029). IMPLICATIONS FOR PRACTICE AND RESEARCH: Role-modeling behaviors of clinical staff may reduce the risk of sleep-related infant deaths upon discharge. A multifactorial approach can leverage successful strategies for improving safe sleep compliance in a NICU setting.

DDK dependent regulation of TOP2A at centromeres revealed by a chemical genetics approach.

In eukaryotic cells the CDC7/DBF4 kinase, also known as DBF4-dependent kinase (DDK), is required for the firing of DNA replication origins. CDC7 is also involved in replication stress responses and its depletion sensitises cells to drugs that affect fork progression, including Topoisomerase 2 poisons. Although CDC7 is an important regulator of cell division, relatively few substrates and bona-fide CDC7 phosphorylation sites have been identified to date in human cells. In this study, we have generated an active recombinant CDC7/DBF4 kinase that can utilize bulky ATP analogues. By performing in vitro kinase assays using benzyl-thio-ATP, we have identified TOP2A as a primary CDC7 substrate in nuclear extracts, and serine 1213 and serine 1525 as in vitro phosphorylation sites. We show that CDC7/DBF4 and TOP2A interact in cells, that this interaction mainly occurs early in S-phase, and that it is compromised after treatment with CDC7 inhibitors. We further provide evidence that human DBF4 localises at centromeres, to which TOP2A is progressively recruited during S-phase. Importantly, we found that CDC7/DBF4 down-regulation, as well S1213A/S1525A TOP2A mutations can advance the timing of centromeric TOP2A recruitment in S-phase. Our results indicate that TOP2A is a novel DDK target and have important implications for centromere biology.

Hypoxia Suppressed Copper Toxicity during Early Development in Zebrafish Embryos in a Process Mediated by the Activation of the HIF Signaling Pathway.

Hypoxia is a global and increasingly important stressor in aquatic ecosystems, with major impacts on biodiversity worldwide. Hypoxic waters are often contaminated with a wide range of chemicals but little is known about the interactions between these stressors. We investigated the effects of hypoxia on the responses of zebrafish (Danio rerio) embryos to copper, a widespread aquatic contaminant. We showed that during continuous exposures copper toxicity was reduced by over 2-fold under hypoxia compared to normoxia. When exposures were conducted during 24 h windows, hypoxia reduced copper toxicity during early development and increased its toxicity in hatched larvae. To investigate the role of the hypoxia signaling pathway on the suppression of copper toxicity during early development, we stabilized the hypoxia inducible factor (HIF) pathway under normoxia using a prolyl-4-hydroxylase inhibitor, dimethyloxalylglycine (DMOG) and demonstrated that HIF activation results in a strong reduction in copper toxicity. We also established that the reduction in copper toxicity during early development was independent of copper uptake, while after hatching, copper uptake was increased under hypoxia, corresponding to an increase in copper toxicity. These findings change our understanding of the current and future impacts of worldwide oxygen depletion on fish communities challenged by anthropogenic toxicants.

Evaluation of a Communication Skills Training Program for Companion-Animal Veterinarians: A Pilot Study Using RIAS Coding.

Effective veterinarian communication skills training and the related key outcomes provided the impetus for this study. We implemented a pre-experimental pre-test/post-test single-group design with a sample of 13 veterinarians and their 71 clients to evaluate the effects of a 6.5-hour communication skills intervention for veterinarians. Consultations were audiotaped and analyzed with the Roter Interaction Analysis System (RIAS). Clients completed the Consultation and Relational Care Measure, a global satisfaction scale, a Parent Medical Interview Satisfaction Scale, and the Adherence Intent measure. Veterinarians completed a communication confidence measure and a workshop satisfaction scale. Contrary to expectation, neither veterinarian communication skills nor their confidence improved post-training. Despite client satisfaction and perceptions of veterinarians' relational communication skills not increasing, clients nevertheless reported an increased intent to adhere to veterinarian recommendations. This result is important because client adherence is critical to managing and enhancing the health and well-being of animals. The results of the study suggest that while the workshop was highly regarded, either the duration of the training or practice opportunities were insufficient or a booster session was required to increase veterinarian confidence and integration of new skills. Future research should utilize a randomized control study design to investigate the appropriate intervention with which to achieve change in veterinarian communication skills. Such change could translate to more effective interactions in veterinarians' daily lives.

Clinical communication skills learning outcomes among first year medical students are consistent irrespective of participation in an interview for admission to medical school.

BACKGROUND: Although contentious most medical schools interview potential students to assess personal abilities such as communication. AIMS: To investigate any differences in clinical communication skills (CCS) between first year students admitted to UQ medical school with or without an admissions interview. METHODS: A retrospective analysis of 1495 student assessment scores obtained after structured communication skills training (CCS) between 2007 and 2010. RESULTS: The average assessment score was 3.76 ([95% CI, 3.73-3.78]) and adjusting for student characteristics, showed no main effect for interview (p = 0.89). The strongest predictor of scores was gender with females achieving significantly higher scores (3.91 [95% CI, 3.54-4.28] vs. 3.76 [95% CI, 3.39-4.13]; p ≤ 0.001). CONCLUSIONS: Data show no differences in post-training assessment measures between students who were interviewed during selection or not. Further research about the quality and retention of communications skills after training is warranted.

Autonomy-connection tensions, stress, and attachment: The case of COVID-19.

The COVID pandemic, and actions taken by governments worldwide to deal with it, have placed stress on couple relationships. Reports from many countries have documented substantial increases in relationship difficulties, conflict, and violence. We propose that issues concerning autonomy and connection are central to these problems, particularly as couples face changing situations with regard to lockdowns, social distancing, and border closures. We further propose that a fruitful approach to understanding these difficulties comes from integrating attachment theory with key concepts of stress and coping theories. Based on these principles and concepts, emotionally focused couples therapy (EFT) offers guidelines to help couples navigate the multiple stressors associated with the pandemic.

Patient-reported outcome measures in MS: Do development processes and patient involvement support valid quantification of clinically important variables?

Background: Patient-reported outcomes (PROs) are widely measured in multiple sclerosis (MS) studies. However, the quality of instrument development processes varies, raising concerns about the meaningfulness of associated data. Objectives: To review the development of selected PROs commonly used in MS studies, including definitions of the concepts measured, use of conceptual frameworks, and degree of input from people living with MS (PlwMS). To gain insights and recommendations from PlwMS on their experience with these PROs. Methods: We assessed 6 PROs (FSIQ-RMS, modified-FIS, MSQoL-54, Leeds 8-item MSQoL, MSIS-29 and EQ-5D) for alignment with regulatory and scientific requirements on PRO structure/development. PlwMS evaluated the degree to which the PROs reflect disease aspects they perceive important. Results: Definitions, clarifications and conceptualisations of the measurement variables were often lacking. PlwMS were variably involved in PRO development. Ethnic diversity was rarely documented. PlwMS identified individualisation, ease of understanding, time burden, and mode of administration as factors affecting PRO usability. Conclusions: To date, the PRO development process has consistently lacked clear definitions of concepts of interest, use of conceptual frameworks and patient involvement, thereby compromising the validity of data they generate. PRO instrument development must be conducted more robustly to maximise the value of pivotal clinical trials.

Approaches to Test the Neurotoxicity of Environmental Contaminants in the Zebrafish Model: From Behavior to Molecular Mechanisms.

The occurrence of neuroactive chemicals in the aquatic environment is on the rise and poses a potential threat to aquatic biota of currently unpredictable outcome. In particular, subtle changes caused by these chemicals to an organism's sensation or behavior are difficult to tackle with current test systems that focus on rodents or with in vitro test systems that omit whole-animal responses. In recent years, the zebrafish (Danio rerio) has become a popular model organism for toxicological studies and testing strategies, such as the standardized use of zebrafish early life stages in the Organisation for Economic Co-operation and Development's guideline 236. In terms of neurotoxicity, the zebrafish provides a powerful model to investigate changes to the nervous system from several different angles, offering the ability to tackle the mechanisms of action of chemicals in detail. The mechanistic understanding gained through the analysis of this model species provides a good basic knowledge of how neuroactive chemicals might interact with a teleost nervous system. Such information can help infer potential effects occurring to other species exposed to neuroactive chemicals in their aquatic environment and predicting potential risks of a chemical for the aquatic ecosystem. In the present article, we highlight approaches ranging from behavioral to structural, functional, and molecular analysis of the larval zebrafish nervous system, providing a holistic view of potential neurotoxic outcomes. Environ Toxicol Chem 2021;40:989-1006. © 2020 SETAC.

Matrix-enhanced secondary ion mass spectrometry (ME SIMS) using room temperature ionic liquid matrices.

Room temperature ionic liquids (ILs) have many applications including as matrices in MALDI. We wished to investigate the efficacy of ILs as matrices in time-of-flight secondary ion mass spectrometry and in mass spectrometric imaging (MS imaging). Two ILs derived from alpha-cyano-4-hydroxycinnamic acid (CHCA) were synthesized and tested using phospholipids, cholesterol, and peptides. The molecular ion intensities of 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC), 1,2-dipalmitoyl-sn-glycero-3-phosphoethanolamine (DPPE), cholesterol, and bradykinin were greatly increased using IL matrices. Further, detection limits were also improved: for DPPC and DPPE detection, limits were at least 2 orders of magnitude better using IL matrices. However, these IL matrices were not effective for the enhancement of angiotensin I ions. The data also indicate that IL matrices are suitable for imaging MS. The IL matrices did not cause changes to the sample surface via matrix crystallization or other processes; no "hot spots" were observed in the mass spectra. As a demonstration, an onionskin membrane was imaged. In the matrix-enhanced MS images, ions characteristic of proteins and other biomolecules were observed which could not otherwise be observed. Clearly ionic liquids deserve further investigation in SIMS and MS imaging.

Hydronephrosis Due to Bilateral Tubo-ovarian Abscess.

A 27-year-old female presented to the emergency department with fevers, nausea, chills, and non-specific bilateral lower quadrant abdominal pain. A pregnancy test was negative. Computed tomography demonstrated moderate left hydronephrosis secondary to tubo-ovarian abscess (TOA). The abscess was so large it distorted local anatomy and compressed the ureters. She was prescribed merepenem and admitted for care by obstetrics/gynecology.

Hypoxia modifies the response to flutamide and linuron in male three-spined stickleback (Gasterosteus aculeatus).

Hypoxia is a major stressor in aquatic environments and it is frequently linked with excess nutrients resulting from sewage effluent discharges and agricultural runoff, which often also contain complex mixtures of chemicals. Despite this, interactions between hypoxia and chemical toxicity are poorly understood. We exposed male three-spined stickleback during the onset of sexual maturation to a model anti-androgen (flutamide; 250 µg/L) and a pesticide with anti-androgenic activity (linuron; 250 µg/L), under either 97% or 56% air saturation (AS). We assessed the effects of each chemical, alone and in combination with reduced oxygen concentration, by measuring the transcription of spiggin in the kidney, as a marker of androgen signalling, and 11 genes in the liver involved in some of the molecular pathways hypothesised to be affected by the exposures. Spiggin transcription was strongly inhibited by flutamide under both AS conditions. In contrast, for linuron, a strong inhibition of spiggin was observed under 97% AS, but this effect was supressed under reduced air saturation, likely due to interactions between the hypoxia inducible factor and the aryl hydrocarbon receptor (AhR) pathways. In the liver, hypoxia inducible factor 1α was induced following exposure to both flutamide and linuron, however this was independent of the level of air saturation. This work illustrates the potential for interactions between hypoxia and pollutants with endocrine or AhR agonist activity to occur, with implications for risk assessment and management.

Enhanced protein detection using a trapping mode on a hybrid quadrupole linear ion trap (Q-Trap).

A novel method to improve the detection of protein ions using a linear ion trap mass spectrometer is presented. A scan function combining charge separation with segmented transmission of multiply charged ions was developed to enhance the sensitivity and resolution of the linear ion trap for the nanoLC-MS analysis of intact proteins. The analytical benefits of the present method are particularly apparent in protein analyses, where the increased proportion of multiply charged ions can exacerbate space-charge effects and compromise the dynamic range of the linear ion trap instrument. The enhanced ion storage and charge separation capabilities of our targeted and enhanced multiply charged scan mode provided a 4-fold increase in signal-to-noise and 5-fold increase in resolution, thus enabling the detection of closely related protein isoforms. The application of this method is demonstrated for low femtomole detection of protein standards and nuclear extracts enriched in histone proteins. The enhanced resolution of this scan mode also enabled us to monitor subtle changes in the methylation of a subpopulation of histone H3 that occurs in chicken DT40 cells lacking specific methyltransferase activity. The extent of the fold change and PTM site localization was performed using predictive software tools and targeted multiple reaction monitoring analysis of histone peptides. Monomethylation of Lys 79 in histone H3 (H3K79me1) was down regulated by 240-fold in methyltransferase deficient cells.

53BP1: function and mechanisms of focal recruitment.

53BP1 (p53-binding protein 1) is classified as a mediator/adaptor of the DNA-damage response, and is recruited to nuclear structures termed foci following genotoxic insult. In the present paper, we review the functions of 53BP1 in DNA-damage checkpoint activation and DNA repair, and the mechanisms of its recruitment and activation following DNA damage. We focus in particular on the role of covalent histone modifications in this process.

Attachment, conflict and relationship quality: laboratory-based and clinical insights.

Severe or persistent conflict is disturbing for romantic partners and can jeopardize the couple relationship, hence activating the attachment system. In this paper we integrate recent laboratory-based and clinical research into attachment processes and couple conflict. Three main tenets are addressed. First, attachment security and insecurity have pervasive effects in conflict situations, shaping perceptual, physiological and behavioral responses to conflict. Second, attachment insecurity and associated conflict behaviors tend to erode relationship quality. Third, attachment-related interventions are effective not only in reducing the maladaptive responses that lead to conflict escalation, but also in promoting security and emotional connection within the couple bond. These findings attest to the key role of attachment processes in conflict interactions, while offering a clear, theory-based framework for intervention.

Munson's Sign: An Obvious Finding to Explain Acute Vision Loss.

Keratoconus is a progressive disorder affecting the cornea, which causes the cornea to become weakened and conical in appearance. The resultant decrease in structural integrity of the cornea predisposes affected individuals to acute corneal hydrops, a break in Descemet's membrane, the deepest layer of the cornea, resulting in pain and acute vision loss. We present here a case of this little-known cause of acute vision loss, and an example of Munson's sign, which is a v-shaped protrusion of the lower eyelid on downward gaze that is characteristic of advanced keratoconus. We hope to highlight Munson's sign as a simple identifier of keratoconus in an otherwise undiagnosed individual suspected of having acute corneal hydrops.

Prevalence of Post-Traumatic Stress Disorder in Emergency Physicians in the United States.

INTRODUCTION: There is increasing concern about the effects of occupational stressors on the wellness of healthcare providers. Given high patient acuity, circadian rhythm disruption, and other workplace stressors, emergency physicians (EP) would be predicted to have high rates of occupational stress. We conducted this study to assess the prevalence of post-traumatic stress disorder (PTSD) in attending EPs practicing in the United States. METHODS: A link to an electronic questionnaire was distributed through the emergency medicine-centric publication Emergency Medicine News. We compared the prevalence of PTSD in EPs to the general population using a chi-square goodness of fit test, and performed logistic regression to assess for significance of risk factors. RESULTS: We received survey responses from 526 persons. In this study, EPs had a PTSD point prevalence of 15.8%. Being a victim of a prior trauma or abuse is the primary predictor of PTSD (odds ratio [OR] [95% confidence interval {CI}, 2.16 (1.21 - 3.86)], p = 0.009) and PTSD severity score (OR [95% CI, 1.16 (1.07 - 1.26)], p <0.001). CONCLUSION: Emergency physicians have a substantial burden of PTSD, potentially jeopardizing their own health and career longevity. Future studies should focus on identifying subgroups at higher risk for PTSD and modifiable risk factors. Prevention and treatment strategies should be developed and tested in healthcare providers.

Emergence of consistent intra-individual locomotor patterns during zebrafish development.

The analysis of larval zebrafish locomotor behavior has emerged as a powerful indicator of perturbations in the nervous system and is used in many fields of research, including neuroscience, toxicology and drug discovery. The behavior of larval zebrafish however, is highly variable, resulting in the use of large numbers of animals and the inability to detect small effects. In this study, we analyzed whether individual locomotor behavior is stable over development and whether behavioral parameters correlate with physiological and morphological features, with the aim of better understanding the variability and predictability of larval locomotor behavior. Our results reveal that locomotor activity of an individual larva remains consistent throughout a given day and is predictable throughout larval development, especially during dark phases, under which larvae demonstrate light-searching behaviors and increased activity. The larvae's response to startle-stimuli was found to be unpredictable, with no correlation found between response strength and locomotor activity. Furthermore, locomotor activity was not associated with physiological or morphological features of a larva (resting heart rate, body length, size of the swim bladder). Overall, our findings highlight the areas of intra-individual consistency, which could be used to improve the sensitivity of assays using zebrafish locomotor activity as an endpoint.

Sublethal exposure to copper supresses the ability to acclimate to hypoxia in a model fish species.

Hypoxia is one of the major threats to biodiversity in aquatic systems. The association of hypoxia with nutrient-rich effluent input into aquatic systems results in scenarios where hypoxic waters could be contaminated with a wide range of chemicals, including metals. Despite this, little is known about the ability of fish to respond to hypoxia when exposures occur in the presence of environmental toxicants. We address this knowledge gap by investigating the effects of exposures to different levels of oxygen in the presence or absence of copper using the three-spined sticklebacks (Gasterosteus aculeatus) model. Fish were exposed to different air saturations (AS; 100%, 75% and 50%) in combination with copper (20 µg/L) over a 4 day period. The critical oxygen level (Pcrit), an indicator of acute hypoxia tolerance, was 54.64 ± 2.51% AS under control conditions, and 36.21 ± 2.14% when fish were chronically exposed to hypoxia (50% AS) for 4 days, revealing the ability of fish to acclimate to low oxygen conditions. Importantly, the additional exposure to copper (20 µg/L) prevented this improvement in Pcrit, impairing hypoxia acclimation. In addition, an increase in ventilation rate was observed for combined copper and hypoxia exposure, compared to the single stressors or the controls. Interestingly, in the groups exposed to copper, a large increase in variation in the measured Pcrit was observed between individuals, both under normoxic and hypoxic conditions. This variation, if observed in wild populations, may lead to selection for a tolerant phenotype and alterations in the gene pool of the populations, with consequences for their sustainability. Our findings provide strong evidence that copper reduces the capacity of fish to respond to hypoxia by preventing acclimation and will inform predictions of the consequences of global increases of hypoxia in water systems affected by other pollutants worldwide.