Immunomodulation of endothelial cells induced by macrolide therapy in a model of septic stimulation.

OBJECTIVES: Sepsis is defined as the host's inflammatory response to a life-threatening infection. The endothelium is implicated in immunoregulation during sepsis. Macrolides have been proposed to display immunomodulatory properties. The goal of this study was to analyze whether macrolides can exert immunomodulation of endothelial cells (ECs) in an experimental model of sepsis. METHODS: Human ECs were stimulated by proinflammatory cytokines and lipopolysaccharide before exposure to macrolides. ECs phenotypes were analyzed by flow cytometry. Cocultures of ECs and peripheral blood mononuclear cells (PBMCs) were performed to study the ECs ability to alter T-cell viability and differentiation in the presence of macrolides. Soluble factor production was assessed. RESULTS: ECs act as non-professional antigen presenting cells and expressed human leukocyte antigen (HLA) antigens, the adhesion molecules CD54, CD106, and the coinhibitory molecule CD274 after septic stimulation. Incubation with macrolides induced a significant decrease of HLA class I and HLA class II HLA-DR on septic-stimulated ECs, but did not alter either CD54, CD106, nor CD274 expression. Interleukin-6 (IL-6) and IL-8 production by stimulated ECs were unaltered by incubation with macrolides, whereas Clarithromycin exposure significantly decreased IL-6 gene expression. In cocultures of septic ECs with PBMCs, neither the proportion of CD4 + , CD8 + T nor their viability was altered by macrolides. T-helper lymphocyte subsets Th1, Th17, and Treg polarization by stimulated ECs were unaltered by macrolides. CONCLUSION: This study reports phenotypic and gene expression changes in septic-stimulated ECs exposed to macrolides, without resulting in altered immunogenicity of ECs in co-cultures with PBMCs. In vivo studies may help to further understand the impact of macrolide therapy on ECs immune homeostasis during sepsis.

A Two-Stage Flow Cytometry Strategy to Distinguish Single Cells from Doublets in Heterogeneous Cell Mixtures and Improve Cell Cluster Identification: Application to Human Monocyte Subpopulations.

Flow cytometry is a powerful method, widely used to identify cell types present in tissues, to describe their phenotypes, and to purify cells for functional analyses. As a single cell technique, flow cytometry relies on identifying and excluding cell doublets and aggregates present in samples in the initial gating steps. This identification is based on detection of events generating electrical pulses falling outside of linear variations of pulse height, width, and area in a singlet population with increasing cell sizes. In heterogeneous cell mixtures, however, with cell types varying extensively in size and granularity, exclusion of doublets has the risk of removing single cells that co-localize with doublets of another cell type. This is particularly the case when doublets of a smaller cell type overlap with large cells of a distinct, larger cell type. Here, we describe a gating method to reduce this risk. In this protocol, initial gating steps aim to segregate cells according to physical characteristics (such as size and granularity) and gene expression properties in order to obtain more homogeneous cell clusters. Doublet exclusion is then performed separately in each cluster, minimizing the risk of confusion between single cells and doublets. To illustrate this protocol, human blood monocytes are separated and analyzed. By implementing this protocol, we were able to reveal the existence of a population of large monocytes previously unrecognized using conventional gating strategies. In subsequent functional assays, we have shown that this novel population exhibits unique inflammatory responses, highlighting the need and pertinence of this approach to identify and characterize infrequent-yet functionally relevant-cell populations present in complex cell mixtures. © 2021 Wiley Periodicals LLC. Basic Protocol: Distinguishing single cells from doublets in heterogeneous cell mixtures by flow cytometry.

Genetic landscape of adult Langerhans cell histiocytosis with lung involvement.

The clinical significance of the BRAF V600E mutation in adult Langerhans cell histiocytosis (LCH), including pulmonary Langerhans cell histiocytosis (PLCH), is not well understood. Similarly, the spectrum of molecular alterations involved in adult LCH has not been fully delineated. To address these issues, we genotyped a large number of adult LCH biopsies and searched for an association of identified molecular alterations with clinical presentation and disease outcome.Biopsies from 117 adult LCH patients, 83 with PLCH (median age 36.4 years, 56 females, 38 multisystem disease, 79 single system disease, 65 current smokers) were genotyped for the BRAF V600E mutation. In 69 cases, LCH lesions were also genotyped by whole-exome sequencing (WES) or targeted gene panel next-generation sequencing (NGS). Cox models were used to estimate the association of baseline characteristics with the hazard of LCH progression.MAPK pathway alterations were detected in 59 out of 69 cases (86%) (BRAF V600E mutation: 36%, BRAF N486_P490 deletion: 28%, MAP2K1 mutations: 15%, isolated NRAS Q61 mutations: 4%), while KRAS mutations were virtually absent in PLCH lesions. The BRAF V600E mutation was not associated with LCH presentation at diagnosis, including smoking status and lung function, in PLCH patients. BRAF V600E status did not influence the risk of LCH progression over time.Thus, MAPK alterations are present in most lesions from adult LCH patients, particularly in PLCH. Unlike reports in paediatric LCH, BRAF V600E genotyping did not provide additional information on disease outcome. The search for alterations involved in the MAPK pathway, including BRAF deletions, is useful for guiding targeted treatment in selected patients with refractory progressive LCH.

Basic nursing care to prevent nonventilator hospital-acquired pneumonia.

PURPOSE: Nonventilator hospital-acquired pneumonia (NV-HAP) is an underreported and unstudied disease, with potential for measurable outcomes, fiscal savings, and improvement in quality of life. The purpose of our study was to (a) identify the incidence of NV-HAP in a convenience sample of U.S. hospitals and (b) determine the effectiveness of reliably delivered basic oral nursing care in reducing NV-HAP. DESIGN: A descriptive, quasi-experimental study using retrospective comparative outcomes to determine (a) the incidence of NV-HAP and (b) the effectiveness of enhanced basic oral nursing care versus usual care to prevent NV-HAP after introduction of a basic oral nursing care initiative. METHODS: We used the International Statistical Classification of Diseases and Related Problems (ICD-9) codes for pneumonia not present on admission and verified NV-HAP diagnosis using the U.S. Centers for Disease Control and Prevention diagnostic criteria. We completed an evidence-based gap analysis and designed a site-specific oral care initiative designed to reduce NV-HAP. The intervention process was guided by the Influencer Model (see Figure) and participatory action research. FINDINGS: We found a substantial amount of unreported NV-HAP. After we initiated our oral care protocols, the rate of NV-HAP per 100 patient days decreased from 0.49 to 0.3 (38.8%). The overall number of cases of NV-HAP was reduced by 37% during the 12-month intervention period. The avoidance of NV-HAP cases resulted in an estimated 8 lives saved, $1.72 million cost avoided, and 500 extra hospital days averted. The extra cost for therapeutic oral care equipment was $117,600 during the 12-month intervention period. Cost savings resulting from avoided NV-HAP was $1.72 million. Return on investment for the organization was $1.6 million in avoided costs. CONCLUSIONS: NV-HAP should be elevated to the same level of concern, attention, and effort as prevention of ventilator-associated pneumonia in hospitals. CLINICAL RELEVANCE: Nursing needs to lead the way in the design and implementation of policies that allow for adequate time, proper oral care supplies, ease of access to supplies, clear procedures, and outcome monitoring ensuring that patients are protected from NV-HAP.

Veteran experiences related to participation in shared medical appointments.

UNLABELLED: Shared medical appointments (SMAs) are an innovative way for multidisciplinary teams to work together to meet veteran needs and encourage adherence to healthy lifestyle recommendations. OBJECTIVE: The purpose of this study was to explore the experiences of veterans who participated in SMAs. METHOD: Focus groups were utilized to obtain information about SMA experiences. This method encouraged veterans to expand on and clarify the meaning of their experiences. Audio recordings were transcribed and analyzed by the researchers using N'Vivo software and an exploratory process to obtain consensus about themes. RESULTS: The following themes emerged as a result of the focus group analysis: "empowerment, peer support, awareness, positive provider characteristics, teamwork, benefits, and convenience." CONCLUSIONS: Veterans reported improvement in their overall health and well-being, improved self-management skills, and satisfaction with the SMA format. Veterans reported feeling empowered to improve their health and described a deep connection with their peers and group leaders. The connection they experienced with other veterans in the SMAs was similar to the close-knit relationships held with other members of their military unit.

Healthcare utilization among patients with vocal cord dysfunction.

BACKGROUND: Acute asthma-like symptoms are anxiety producing for patients, and improper diagnosis leads to inappropriate use of asthma medications, unnecessary office and emergency room visits and referral to specialists to determine the cause. Vocal cord dysfunction (VCD) is responsible for 15% of referrals for dyspnea on exertion and frequently leads to multiple emergency room visits. PURPOSE: The purpose of this study was to explore healthcare utilization among patients with VCD compared to patients with asthma and report the demographic characteristics of patients with these diagnoses receiving outpatient specialty care. METHODS: In this retrospective study, the de-identified electronic medical records of 285 participants receiving outpatient specialty care with a documented diagnosis of VCD, asthma, and VCD and asthma during the years 2007-2009 were explored with descriptive statistics, chi square, and Poisson regression. RESULTS: Despite the perception of overuse of medical resources among patients with VCD, participants in this study were seen in the outpatient clinic less frequently than participants with asthma, they used less inhaled controller medication, and there were no reported emergency room visits or hospitalizations. Females were more likely to experience this disorder. Patients with VCD were twice as likely to receive medication for anxiety and/or depression, which suggests that mood is a contributor to this disorder. Past or current allergy immunotherapy was utilized by nearly half the sample, which greatly reduces the triggers associated with VCD symptoms and asthma exacerbations. It is surmised that appropriate management including allergy immunotherapy and patient education impacted the use of hospital and outpatient services. Estimated controller inhaler costs for the entire sample were surprisingly high. Use of a controller inhaler, however, was significantly lower among patients with VCD as compared to patients with asthma which is appropriate. CONCLUSION: Nurse practitioners and other healthcare providers are challenged to reduce unnecessary inhaler prescribing among patients with VCD without asthma and to seek specialty consultation to confirm or refute the diagnosis of asthma when needed.

Doctoral persistence and doctoral program completion among nurses.

PROBLEM: The United States is experiencing a critical shortage of registered nurses, which is due to multiple factors, including a deficit of full-time doctorally prepared nursing faculty. METHODS AND FINDINGS: This review of the literature addresses doctoral persistence and the challenges faced by doctoral nursing students. Themes found in this review included periods of transition, parenthood and outside demands, delays and "marinating" in the data, and positive aspects. These issues need to be addressed in order to increase doctoral student retention and reverse the nursing shortage.

Veteran tobacco use, low-density lipoprotein, and glycated hemoglobin levels.

The deidentified electronic medical records of 1,452 veterans with a history of smoking and assigned to an outpatient Department of Veteran Affairs Medical Center were examined. Descriptive statistics and two repeated measures ANCOVA were performed to determine the demographic characteristics of the sample and the relationships between the independent variable of tobacco use group on the dependent variables of LDL cholesterol and HbA1c levels, during the years 2003 through 2007. There was no statistically significant relationship between tobacco use and LDL levels when controlling for weight. There was a statistically significant difference in the tobacco use groups and HbA1c levels. Current smokers had higher HbA1c levels than did former smokers throughout the observational period, but the difference was statistically significant only for the years 2003 and 2007. Thus health care providers are challenged to monitor for cardiovascular risk factors, assist patients with smoking cessation, and prevent tobacco use.

Provider adherence to clinical guidelines related to lipid-lowering medications.

The objective of this study was to determine whether health care providers at the Department of Veterans Affairs Medical Center (VAMC) in Salem, Virginia were adherent to lipid-lowering medication guidelines over a 5-year period. Five hundred randomly chosen electronic medical records of veterans with diabetes, congestive heart failure, and/or coronary artery disease were examined for the use of HMG-CoA reductase inhibitors as part of a larger study on patient-provider adherence to cardiovascular risk-reduction guidelines. Study findings indicated that health care providers prescribed HMG-CoA reductase inhibitors to patients at high risk per evidence-based guidelines. Provider adherence to guidelines rose each year of the study, which coincided with the Department of Veterans Affairs Medical Center efforts to educate health care providers about the evidence-based guidelines, utilization of computer-generated reminders, open access appointment scheduling, and increased collaboration with patients.

Concept analysis of adherence in the context of cardiovascular risk reduction.

TOPIC: Cardiovascular disease is the number one cause of death in the United States. Examination of the concept of adherence is essential to provide informed patient-centered care to prevent the development and progression of this largely preventable disease. OBJECTIVE: The purpose of this concept analysis is to explore and clarify the concept of adherence. This analysis will provide a framework for those seeking a better understanding of patient decision-making, reduction of relapse to unhealthy behaviors, and increased long-term adherence to cardiovascular health recommendations. Reviews of major theories related to health behavior are reviewed in the second part of the article and are linked to the concept of adherence. METHOD: Following a review of the literature, Morse's guidelines were utilized to present a concept analysis of adherence and the related terms concordance and compliance from the disciplines of nursing, health psychology, ethics, pharmacy, and medicine. RESULTS: Adherence is dependent on the collaborative relationship between patient and healthcare provider. Adherence is influenced by the meaning of health, heart disease, and sense of personal risk as well as socioeconomic status, decision support, motivation, and desire for change, self-efficacy, and sources of credible health information. Attributes of successful adherence include alignment of patient behavior and health recommendations, mastery of new health knowledge and behavior, continued collaborative relationships between the patient and healthcare provider, and ability to meet outcome targets. CONCLUSION: Adherence is defined as persistence in the practice and maintenance of desired health behaviors and is the result of active participation and agreement. Adherence is dependent on the development of a concordant relationship and its measurement should be specific utilizing the correct tools. Special attention should be paid to shared decision-making between patient and healthcare provider.

Themes in the literature related to cardiovascular disease risk reduction.

PURPOSE: This article aimed to identify themes in the literature related to patient-healthcare provider beliefs, barriers to adherence, and interventions pertaining to cardiovascular disease risk reduction. METHODS: Twenty quantitative and qualitative primary research studies including 2 meta-analyses published between 1995 and 2008 were analyzed for themes and practice implications to synthesize existing research on cardiovascular disease risk reduction. Databases searched included EBSCO, CINAHL, MEDLINE, ScienceDirect, HealthSource, and PsychLit using the search terms patient- provider adherence, adherence and shared decision making, adherence and decision support, patient- provider goal setting, and cardiovascular disease risk reduction. RESULTS: The emergent themes found in this literature review included (1) complex medication regimens; (2) risk perception, quality of life, and competing priorities; (3) motivation for change; (4) provider clinical inertia; and (5) goal setting, feedback, and reminders. Studies reporting the highest rates of adherence to cardiovascular disease risk reduction recommendations incorporated patient-provider goal setting and decision support, self-management techniques, and personalized printed communication. IMPLICATIONS FOR PRACTICE: Goal setting in cardiovascular disease risk reduction is a relatively unexplored area and is an important component of shared decision making and adherence to cardiovascular disease health recommendations. The following review will address the 5 themes identified in more detail and provide a basis for improved clinical practice.

Jaundice in the full-term newborn.

Jaundice is a common problem affecting over half of all full-term and most preterm infants. Jaundice describes the yellow orange hue of the skin caused by excessive circulating levels of bilirubin that accumulate in the skin. In most healthy full-term newborns, jaundice is noticed during the first week of life. Shortened hospital stays and inconsistent follow up, especially for first-time breastfeeding mothers, prompted the American Academy of Pediatrics (AAP) to update management guidelines. Health care providers need to be familiar with the diagnosis and management of jaundice to prevent brain, vision, and hearing damage. Treatment of choice for jaundice remains close observation and frequent feeding followed by phototherapy, and finally exchange transfusion for severe or refractory cases.