The impact of frailty and rapid response team activation on patients admitted to the intensive care unit: A case-control matched, observational, single-centre cohort study.

BACKGROUND: Frailty is a multi-dimensional syndrome associated with mortality and adverse outcomes in patients admitted to the intensive care unit (ICU). Further investigation is warranted to explore the interplay among factors such as frailty, clinical deterioration triggering a medical emergency team (MET) review, and outcomes following admission to the ICU. METHODS: Single-centre, retrospective observational case-control study of adult patients (>18 years) admitted to a medical-surgical ICU with (cases) or without (controls) a preceding MET review between 4 h and 14 days prior. Matching was performed for age, ICU admission diagnosis, Acute Physiology and Chronic Health Evaluation III (APACHE III) score and the 8-point Clinical Frailty Scale (CFS). Cox proportional hazard regression modelling was performed to determine associations with 30-day mortality after admission to ICU. RESULTS: A total of 2314 matched admissions were analysed. Compared to non-frail patients (CFS 1-4), mortality was higher in all frail patients (CFS 5-8), at 31% vs. 13%, and in frail patients admitted after MET review at 33%. After adjusting for age, APACHE, antecedent MET review and CFS in the Cox regression, mortality hazard ratio increased by 26% per CFS point and by 3% per APACHE III point, while a MET review was not an independent predictor. Limitations of medical treatment occurred in 30% of frail patients, either with or without a MET antecedent, and this was five times higher compared to non-frail patients. CONCLUSION: Frail patients admitted to ICU have a high short-term mortality. An antecedent MET event was associated with increased mortality but did not independently predict short-term survival when adjusting for confounding factors. The intrinsic significance of frailty should be primarily considered during MET review of frail patients. This study suggests that routine frailty assessment of hospitalised patients would be helpful to set goals of care when admission to ICU could be considered.

I'm still me, I'm still a person: war metaphor use and meaning making in women with metastatic breast cancer.

PURPOSE: The war metaphor is one strategy used frequently in breast cancer to inspire individuals in a "fight" against cancer and assist patients in navigating their illness experience. Despite prominent use, the emotional impact of this language has not been examined in the context of meaning making among women with metastatic breast cancer (MBC). METHODS: This study involved a semi-structured interview considering the war metaphor's impact on women's illness experience with MBC. Participants (n = 22) had been diagnosed with MBC for at least 6 months or following 1 disease progression and were undergoing treatment at an NCI-designated cancer center in Western Pennsylvania at the time of interview. Each participant underwent an individual interview exploring the war metaphor's impact on illness experience. Qualitative thematic analysis was performed to assess feelings about the war metaphor and emotional response to the lived experience of cancer. RESULTS: Two themes were identified surrounding metaphor use and participants' experiences with meaning making in cancer. First, women with MBC perceive the diagnosis as an "unfair fight" due to its incurable nature. Second, patients use alternative language of "living life" and communicate resistance to being defined by their cancer diagnosis. CONCLUSION: War metaphors are one collection of terminology people use to understand their diagnosis. However, their use may apply pressure to prioritize positivity in the face of diagnosis and treatment, in a unique clinical context where this may not be adaptive. These findings affirm a need to consider patients' lived experiences to best facilitate psychological adjustment to illness.

Elemental analysis of infant airborne particulate exposures.

Air pollution is hypothesized to have negative impacts on infant pulmonary health because of infants' increased rates of respiration and ongoing lung development. The severity and type of impact may differ depending on elemental concentrations. We conducted a study of 21 infants <6 months old whose parents carried a small personal particulate monitoring device (RTI MicroPEM) and GPS unit with the infant for 7 days in January and February 2015. The study area was Utah County, UT, USA. Real-time particulate exposure levels, as well as optical density and elemental analysis of the particulate matter (PM), were compared with levels from an outdoor stationary monitor. Infants spent an average of 87.4% of their time indoors. PM levels varied widely by infant and time of day (average=19.07 µg/m3, range=0.63-170.25 µg/m3). Infant particulate exposures were not well approximated by the outdoor monitor. Infants had lower exposures to Sb, Mn, Pb, W and Fe than the outdoor monitor and higher exposures to Cd, Ni and Na. Differences were most pronounced for Na. Brown carbon was only detected by personal monitors and not by the outdoor monitor. Further research is needed to understand the potential implications of indoor elemental exposures on early respiratory development.

Forehead necrosis, one of the many facades of giant cell arteritis.

Giant cell arteritis (GCA) is known to be a potentially blinding condition. Swift diagnosis can aid in preventing permanent visual loss and, more importantly, protect the contralateral eye. Classical symptoms include jaw claudication, myalgia and new-onset headache. We present two cases of GCA with scalp necrosis, a rare feature associated with this condition. In the first case, forehead necrosis preceded the visual symptoms by 2 days. In the second case it was noted a few weeks after the patient presented with profound unilateral loss of vision. Scalp necrosis is an important sign that should prompt those approached by these patients to consider GCA.

Damage to the optic chiasm in myelin oligodendrocyte glycoprotein-experimental autoimmune encephalomyelitis mice.

Optic chiasm lesions in myelin oligodendrocyte glycoprotein (MOG)-experimental autoimmune encephalomyelitis (EAE) mice were characterized using magnetic resonance imaging (MRI) and validated using electron microscopy (EM). MR images were collected from 3 days after induction to remission, approximately 20 days after induction. Hematoxylin and eosin, solochrome cyanin-stained sections, and EM images were obtained from the optic chiasms of some mice approximately 4 days after disease onset when their scores were thought to be the highest. T2-weighted imaging and apparent diffusion coefficient map hyperintensities corresponded to abnormalities in the optic chiasms of EAE mice. Mixed inflammation was concentrated at the lateral surface. Degeneration of oligodendrocytes, myelin, and early axonal damage were also apparent. A marked increase in chiasm thickness was observed. T2-weighted and diffusion-weighted MRI can detect abnormalities in the optic chiasms of MOG-EAE mice. MRI is an important method in the study of this model toward understanding optic neuritis.

Incompletely excised basal cell carcinoma: residual tumor rates at Mohs re-excision.

BACKGROUND: Basal cell carcinoma (BCC) is the most common skin cancer, and incompletely excised BCC is a commonly encountered clinical scenario. OBJECTIVE: To investigate the incidence of histologic and clinical evidence of residual BCC at Mohs micrographic surgery (MMS) for the treatment of incompletely excised BCC. METHODS AND MATERIALS: One hundred incompletely excised BCCs, from our practice and referred to our practice by local family doctors, treated using MMS between 2005 and 2007 were studied. Patient data included sex, age, anatomic location of tumor, histologic subtype, margin involved, initial closure and closure after MMS, and Mohs stages required for histologic clearance. RESULTS: Sixty-nine percent of incompletely excised BCCs had residual tumor at MMS re-excision, and 12% had clinically evident residual disease. CONCLUSION: Immediate re-excision using MMS is recommended for treatment of incompletely excised BCC because the majority of cases have histologically detectable BCC. Watch and wait advice could lead to significant morbidity because recurrence may necessitate more extensive closures and costs. Long-term follow-up is recommended. It is important to conduct self-audits of incomplete excisions and follow up these patients.

Detection of green fluorescent protein in a single bacterium by capillary electrophoresis with laser-induced fluorescence.

Green fluorescence protein (GFP) is a common reporter used to monitor protein expression in single cells. However, autofluorescence from endogenous components can mask the signal from GFP, particularly at low expression levels in prokaryotes. We employ capillary electrophoresis with laser-induced fluorescence for the analysis of the expression of green fluorescent protein in a single bacterium. Capillary electrophoresis separates GFP from native cellular autofluorescent components, reducing the background signal and improving detection limits. Our system provides 100 ymol (60 copies) limits of detection for GFP. To demonstrate the performance of this instrument, we employ a model system of Deinococcus radiodurans that has been engineered to express GFP under the control of the recA promoter. We report resolution and detection of GFP and autofluorescent components in a single D. radiodurans bacterium. This paper presents the first example of expression of GFP in D. radiodurans and the first detection of GFP in a single bacterium by capillary electrophoresis.

Analysis of differential detergent fractions of an AtT-20 cellular homogenate using one- and two-dimensional capillary electrophoresis.

Differential detergent fractionation was used to sequentially extract cytosolic, membrane, nuclear, and cytoskeletal fractions from AtT-20 cells. Extracted components were denatured by sodium dodecyl sulfate (SDS) and then labeled with the fluorogenic reagent 3-(2-furoyl) quinoline-1-carboxaldehyde. Both capillary sieving electrophoresis (CSE) and micellar electrokinetic capillary chromatography (MECC) were used to separate labeled components by one-dimensional (1D) electrophoresis. Labeled components were also separated by two-dimensional (2D) capillary electrophoresis; CSE was employed in the first dimension and MECC in the second dimension. Roughly 150 fractions were transferred from the first to the second capillary for this comprehensive analysis in 2.5 h.

The neuroprotective action of JNK3 inhibitors based on the 6,7-dihydro-5H-pyrrolo[1,2-a]imidazole scaffold.

Imidazole-based structures of p38 inhibitors served as a starting point for the design of JNK3 inhibitors. Construction of a 6,7-dihydro-5H-pyrrolo[1,2-a]imidazole scaffold led to the synthesis of the (S)-enantiomers, which exhibited p38/JNK3 IC50 ratio of up to 10 and were up to 20 times more potent inhibitors of JNK3 than the relevant (R)-enantiomers. The JNK3 inhibitory potency correlated well with inhibition of c-Jun phosphorylation and neuroprotective properties of the compounds in low K+-induced cell death of rat cerebellar granule neurones.