Transitioning children using home invasive mechanical ventilation from hospital to home: Discharge criteria, disparities, and ethical considerations.

Children using home invasive mechanical ventilation (HIMV), a valuable therapeutic option for chronic respiratory failure, constitute a growing population. Transitioning children using HIMV from hospital to home care is a complex process that requires a multidisciplinary approach involving healthcare professionals, caregivers, and community resources. Medical stability, caregiver competence, and home environment suitability are essential factors in determining discharge readiness. Caregiver education and training play a pivotal role in ensuring safe and effective home care. Simulation training and staged education progression are effective strategies for equipping caregivers with necessary skills. Resource limitations, inadequate home nursing support, and disparities in available community resources are common obstacles to successful HIMV discharge. International perspectives shed light on diverse healthcare systems and challenges faced by caregivers worldwide. While standardizing guidelines for HIMV discharge may be complex, collaboration among healthcare providers and the development of evidence-based regional guidelines can improve outcomes for children using HIMV and their caregivers. This review seeks to synthesize literature, provide expert guidance based on experience, and highlight components to safely discharge children using HIMV. It further assesses disparities and divergences within regional and international healthcare systems while addressing relevant ethical considerations.

Diversity of PA cohorts during the evolution to an entry-level master's degree.

OBJECTIVE: This study evaluated the racial and ethnic diversity of physician associate/assistant (PA) graduating cohorts during the profession's transition from a standard undergraduate degree to an entry-level master's degree. METHODS: Using all existing program reports from the Physician Assistant Education Association (1985-2019), we explored potential associations between changes in tuition, degree types offered, and racial/ethnic makeup of graduating cohorts. RESULTS: We observed a strong negative association between Black students and graduates versus increasing tuition and the rise of master's level programs. CONCLUSIONS: More equitable opportunities for joining the PA profession may be needed.

Cost of pediatric laryngotracheal reconstruction: Differences between single-versus double-stage procedures.

OBJECTIVE: Examine differences in cost between single stage (ss) versus double stage (ds) laryngotracheal reconstruction (LTR) for pediatric subglottic stenosis. STUDY DESIGN: Retrospective chart review of children who underwent ssLTR or dsLTR from 2014 to 2018 at a single institution. METHODS: Costs related to LTR and post-operative care up to one year after tracheostomy decannulation were extrapolated from charges billed to the patient. Charges were obtained from the hospital finance department and the local medical supplies company. Patient demographics including baseline severity of subglottic stenosis and co-morbidities were noted. Variables assessed include duration of hospital admission, number of ancillary procedures, duration of sedation wean, cost of tracheostomy maintenance, and time to tracheostomy decannulation. RESULTS: Fifteen children underwent LTR for subglottic stenosis. D Ten patients underwent ssLTR, while five underwent dsLTR. Grade 3 subglottic stenosis was more prevalent in patients who underwent dsLTR (100%) than ssLTR (50%). The average per-patient hospital charges for ssLTR was $314,383 versus $183,638 for dsLTR. When estimated mean cost of tracheostomy supplies and nursing care until tracheostomy decannulation was included, the mean total charges associated with dsLTR patients was $269,456. Average hospital stay after initial surgery was 22 days for ssLTR versus 6 days for dsLTR. Average time to tracheostomy decannulation for dsLTR was 297 days. Average number of ancillary procedures needed was 3 versus 8 for ssLTR versus dsLTR. CONCLUSION: For pediatric patients with subglottic stenosis, dsLTR may have a lower cost than ssLTR. Although ssLTR has the benefit of immediate decannulation, it is associated with higher patient charges, as well as longer initial hospitalization and sedation. For both patient groups, fees associated with nursing care comprised the majority of charges. Recognizing the factors that contribute to cost differences between ssLTR and dsLTR may be useful when performing cost-benefit analyses and assessing value in health care delivery.

Characteristics of physician associates/assistants in dermatology.

The dermatology workforce includes physicians, nurse practitioners (NPs), and physician associates/assistants (PAs). The number of dermatologists is growing slowly while the growth of PAs working in dermatology is rapid and accelerating. To understand their characteristics, a descriptive study of PAs practicing in dermatology utilizing the National Commission on Certification of Physician Assistants (NCCPA) workforce dataset on PA practices was undertaken. NCCPA certifies PAs who practice in the United States and queries them about their role, employment, salary, and job satisfaction. Analyses consisted of descriptive statistics, Chi-Square, and Mann-Whitney tests for comparisons between PAs practicing in dermatology versus the total of all other PA specialties. As of 2021, 4,580 certified PAs reported practicing in dermatology-a nearly twofold increase since 2013, when 2323 worked in the specialty. This cohort's median age was 39 years, and 82% were female. Almost all (91.5%) are office based, and 81% work more than 31 h per week. The median salary was $125,000 (2020 dollars). Dermatology PAs work fewer hours and see more patients than their counterparts compared to all 69 PA specialties. At the same time, dermatology PAs are more satisfied and less burnt out when compared to all PAs. The increased number of PAs selecting dermatology as their discipline can help lessen the projected physician shortage in this field.

Skin cancer in immunosuppressed patients.

ABSTRACT: The number of people living with chronic immunosuppression is increasing in the United States. Patients with HIV, those who have had bone marrow or solid organ transplants, and patients taking biologics for autoimmune diseases are at increased risk for skin cancer. Skin cancer in these patients is more aggressive and more likely to metastasize and cause death. Medications and individual risk factors such as sex, age, and ethnicity are independent risk factors for the development of skin cancer. Routine screening and aggressive treatment of actinic keratoses and nonmelanoma skin cancers can reduce patients' skin cancer burden and improve patient outcomes.

Cellular and cell-free studies of catalytic DNA cleavage by ruthenium polypyridyl complexes containing redox-active intercalating ligands.

The ruthenium(ii) polypyridyl complexes (RPCs), [(phen)2Ru(tatpp)]2+ (32+ ) and [(phen)2Ru(tatpp)Ru(phen)2]4+ (44+ ) are shown to cleave DNA in cell-free studies in the presence of a mild reducing agent, i.e. glutathione (GSH), in a manner that is enhanced upon lowering the [O2]. Reactive oxygen species (ROS) are involved in the cleavage process as hydroxy radical scavengers attenuate the cleavage activity. Cleavage experiments in the presence of superoxide dismutase (SOD) and catalase reveal a central role for H2O2 as the immediate precursor for hydroxy radicals. A mechanism is proposed which explains the inverse [O2] dependence and ROS data and involves redox cycling between three DNA-bound redox isomers of 32+ or 44+ . Cultured non-small cell lung cancer cells (H358) are sensitive to 32+ and 44+ with IC50 values of 13 and 15 µM, respectively, and xenograft H358 tumors in nude mice show substantial (∼80%) regression relative to untreated tumors when the mice are treated with enantiopure versions of 32+ and 44+ (Yadav et al. Mol Cancer Res, 2013, 12, 643). Fluorescence microscopy of H358 cells treated with 15 µM 44+ reveals enhanced intracellular ROS production in as little as 2 h post treatment. Detection of phosphorylated ATM via immunofluorescence within 2 h of treatment with 44+ reveals initiation of the DNA damage repair machinery due to the ROS insult and DNA double strand breaks (DSBs) in the nuclei of H358 cells and is confirmed using the γH2AX assay. The cell data for 32+ is less clear but DNA damage occurs. Notably, cells treated with [Ru(diphenylphen)3]2+ (IC50 1.7 µM) show no extra ROS production and no DNA damage by either the pATM or γH2AX even after 22 h. The enhanced DNA cleavage under low [O2] (4 µM) seen in cell-free cleavage assays of 32+ and 44+ is only partially reflected in the cytotoxicity of 32+ and 44+ in H358, HCC2998, HOP-62 and Hs766t under hypoxia (1.1% O2) relative to normoxia (18% O2). Cells treated with RPC 32+ show up to a two-fold enhancement in the IC50 under hypoxia whereas cells treated with RPC 44+ gave the same IC50 whether under hypoxia or normoxia.

Cleavage of DNA by proton-coupled electron transfer to a photoexcited, hydrated Ru(II) 1,10-phenanthroline-5,6-dione complex.

Visible light irradiation of a ruthenium(II) quinone-containing complex, [(phen)(2)Ru(phendione)](2+) (1(2+)), where phendione = 1,10-phenanthroline-5,6-dione, leads to DNA cleavage in an oxygen independent manner. A combination of NMR analyses, transient absorption spectroscopy, and fluorescence measurements in water and acetonitrile reveal that complex 1(2+) must be hydrated at the quinone functionality, giving [(phen)(2)Ru(phenH(2)O)](2+) (1H(2)O(2+), where phenH(2)O = 1,10-phenanthroline-6-one-5-diol), in order to access a long-lived (3)MLCT(hydrate) state (τ ∼ 360 ns in H(2)O) which is responsible for DNA cleavage. In effect, hydration at one of the carbonyl functions effectively eliminates the low-energy (3)MLCT(SQ) state (Ru(III) phen-semiquinone radical anion) as the predominant nonradiative decay pathway. This (3)MLCT(SQ) state is very short-lived (<1 ns) as expected from the energy gap law for nonradiative decay, (1) and too short-lived to be the photoactive species. The resulting excited state in 1H(2)O(2+)* has photophysical properties similar to the (3)MLCT state in [Ru(phen)(3)](2+)* with the added functionality of basic sites at the ligand periphery. Whereas [Ru(phen)(3)](2+)* does not show direct DNA cleavage, the deprotonated form of 1H(2)O(2+)* does via a proton-coupled electron transfer (PCET) mechanism where the peripheral basic oxygen sites act as the proton acceptor. Analysis of the small molecule byproducts of DNA scission supports the conclusion that cleavage occurs via H-atom abstraction from the sugar moieties, consistent with a PCET mechanism. Complex 1(2+) is a rare example of a ruthenium complex which 'turns on' both reactivity and luminescence upon switching to a hydrated state.