Impact of Standardized Multidisciplinary Critical Care Training on Confidence with Critical Illness and Attitudes Towards Interprofessional Education and Multidisciplinary Care.

INTRODUCTION: The Fundamental Critical Care Support Course (FCCS) is a standardized multidisciplinary program designed to educate participants on the basics of identification and management of patients with critical illness. Our objective was to evaluate the effect of FCCS participation on confidence in the assessment and management of critically ill patients and attitudes towards multidisciplinary education and interprofessional care in a multidisciplinary group of participants. METHODS: Participants enrolled in the FCCS course from May 2018 to November 2019 were solicited to participate in a series of surveys evaluating their course experience and confidence in critical care. Attitudes towards multidisciplinary education and interprofessional care were evaluated using the Student Perceptions of Interprofessional Clinical Education-Revised Instrument version 2 (SPICE-R2) tool. A prospective pre- and post-design with a self-report survey including retrospective pre-training assessment and a 3-month follow-up was conducted. Statistical analysis was performed using descriptive statics and non-parametric methods. RESULTS: 321 (97.9%) of the course participants enrolled in the study and completed the confidence survey and SPICE-R2 tool pre-course. Nurses (113, 35.4%) and physicians (110, 34.4%) made up the largest groups of participants, although physician assistants and paramedics were also well represented. Confidence in recognition and management of critical illness significantly improved across all studied domains after course completion, with the mean total confidence score improving from 32.96 pre-course to 41.10 post-course, P < 0.001. Attitudes towards multidisciplinary education and interprofessional care also improved (mean score 41.37 pre-course vs 42.71 post-course, P < 0.001), although pre-course numbers were higher than expected which limited the significance to only certain domains. DISCUSSION: In a multidisciplinary group, completion of FCCS training led to increased confidence in all aspects of critical illness measured. A modest increase in attitudes regarding multidisciplinary education and interprofessional care was also demonstrated. Further study is needed to assess whether this increased confidence translates to improvements in patient care and outcomes.

Mid-treatment Fluorodeoxyglucose Positron Emission Tomography in Human Papillomavirus-related Oropharyngeal Squamous Cell Carcinoma Treated with Primary Radiotherapy: Nodal Metabolic Response Rate can Predict Treatment Outcomes.

AIMS: To evaluate whether biomarkers derived from fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) performed prior to (prePET) and during the third week (interim PET; iPET) of radiotherapy can predict treatment outcomes in human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPC). MATERIALS AND METHODS: This retrospective analysis included 46 patients with newly diagnosed OPC treated with definitive (chemo)radiation and all patients had confirmed positive HPV status (HPV+OPC) based on p16 immunohistochemistry. The maximum standardised uptake value (SUVmax), metabolic tumour volume (MTV) and total lesional glycolysis (TLG) of primary, index node (node with the highest TLG) and total lymph nodes and their median percentage (≥50%) reductions in iPET were analysed, and correlated with 5-year Kaplan-Meier and multivariable analyses (smoking, T4, N2b-3 and AJCC stage IV), including local failure-free survival, regional failure-free survival, locoregional failure-free survival (LRFFS), distant metastatic failure-free survival (DMFFS), disease-free survival (DFS) and overall survival. RESULTS: There was no association of outcomes with prePET parameters observed on multivariate analysis. A complete metabolic response of primary tumour was seen in 13 patients; the negative predictive value for local failure was 100%. More than a 50% reduction in total nodal MTV provided the best predictor of outcomes, including LRFFS (88% versus 47.1%, P = 0.006, hazard ratio = 0.153) and DFS (78.2% versus 41.2%, P = 0.01, hazard ratio = 0.234). More than a 50% reduction in index node TLG was inversely related to DMFFS: a better nodal response was associated with a higher incidence of distant metastatic failure (66.7% versus 100%, P = 0.009, hazard ratio = 3.0). CONCLUSION: The reduction (≥50%) of volumetric nodal metabolic burden can potentially identify a subgroup of HPV+OPC patients at low risk of locoregional failure but inversely at higher risk of distant metastatic failure and may have a role in individualised adaptive radiotherapy and systemic therapy.

Neoadjuvant Radiotherapy Dose Escalation in Locally Advanced Rectal Cancer: a Systematic Review and Meta-analysis of Modern Treatment Approaches and Outcomes.

AIMS: Improving pathological complete response (pCR) rates after neoadjuvant chemoradiotherapy for locally advanced rectal cancer may facilitate surgery-sparing treatment paradigms. Radiotherapy boost has been linked to higher rates of pCR; however, outcomes in moderately escalated inverse-planning studies have not been systematically evaluated. We therefore carried out a systematic review and meta-analysis of radiation dose-escalation studies in the context of neoadjuvant therapy for locally advanced rectal cancer. MATERIALS AND METHODS: A systematic search of Pubmed, EMBASE and Cochrane databases for synonyms of 'rectal cancer', 'radiotherapy' and 'boost' was carried out. Studies were screened for radiotherapy prescription >54 Gy. Prespecified quality assessment was carried out for meta-analysis inclusion suitability. Pooled estimates of pCR, acute toxicity (grade ≥3) and R0 resection rates were determined with random-effects restricted maximum-likelihood estimation. Heterogeneity was assessed with Higgins I2 and Cochran Q statistic. Subset analysis examined outcomes in modern inverse-planning studies. Meta-regression with permutation correction was carried out for each outcome against radiation dose, radiotherapy technique, boost technique, chemotherapy intensification and other patient- and treatment-related cofactors. RESULTS: Forty-nine primary and three follow-up publications were included in the systematic review. Pooled estimates of pCR, toxicity and R0 resection across 37 eligible publications (n = 1817 patients) were 24.1% (95% confidence interval 21.2-27.4%), 11.2% (95% confidence interval 7.2-17.0%) and 90.7% (95% confidence interval 87.9-93.8%). Within inverse-planning studies (17 publications, n = 959 patients), these rates were 25.7% (95% confidence interval 21.0-31.1%), 9.8% (95% confidence interval 4.6-19.7%) and 95.3% (95% confidence interval 91.6-97.4%). Regression analysis did not identify any significant predictor of pCR (P > 0.05). CONCLUSIONS: Radiotherapy dose escalation above 54 Gy is associated with high rates of pCR and does not seem to increase the risk of acute grade ≥3 toxicity events. pCR rates approaching 25% may be achievable utilising moderate escalation (54-60 Gy) with modern inverse-planning techniques; however, a clear dose-response relationship was not identified in regression analysis and additional evidence is awaited given the prevalence of heterogenous single-arm studies to date.

Source Apportionment of Coarse Particulate Matter (PM10) in Yangon, Myanmar.

The Republic of the Union of Myanmar is one of many developing countries facing concerns about particulate matter (PM). Previously, a preliminary study of PM2.5 in 2018 suggested that the main source of PM in Yangon, the former capital, was vehicle emissions. However, this suggestion was not supported by any chemical composition data. In this study, to fill that gap, we quantitatively determined source contributions to coarse particulate matter (PM10) in Yangon, Myanmar. PM10 samples were collected in Yangon from May 2017 to April 2018 and chemically analyzed to determine composition. Chemical composition data for these samples were then used in the Chemical Mass Balance (CMB) model to identify the major sources of particulate matter in this area. The results indicate that PM10 composition varies seasonally according to both meteorological factors (e.g., precipitation and temperature) and human activities (e.g., firewood and yard waste burning). The major sources of PM in Yangon annually were dust, secondary inorganic aerosols (SIA), and secondary organic aerosols (SOA), while contributions from biomass burning were more important during the winter months.

Endoscopy gender determination and reproductive hormone profiles of Painted Terrapins (Batagur borneoensis) subjected to ex situ incubation.

Chelonian exhibit temperature dependent sex determination, and ex situ incubation of eggs in conservation hatcheries may render a gender bias. The gender of juvenile Painted terrapins (Batagur borneoensis) produced at a conservation hatchery in Malaysia was determined by endoscopy of the gonads. Circulating reproductive hormones (testosterone, progesterone and estradiol) were profiled for 31 juveniles and nine captive-reared non-breeding adult terrapins. Endoscopy revealed a gender bias of 96.8% (30/31) females. Testosterone levels in the juvenile females (2.49 ± 1.29) were significantly lower than that of the adult females (12.20 ± 4.29), and lower than values in the juvenile male (9.36) and adult males (27.60, 35.62). The progesterone levels in the juvenile females (107.12 ± 68.68) were significantly higher than that of the adult females (51.13 ± 24.67), but lower than values in the juvenile male (33.27) and adult males (3.43, 8.51). Estrogen levels were significantly lower in the juvenile females (1.57 ± 1.35) compared to the adult females (77.46 ± 53.45). Negative correlations were observed between levels of progesterone and testosterone, and progesterone and estrogen. A positive correlation was noted between estrogen and testosterone. The present study constitutes the first attempt to determine the gender and reproductive hormone profiles of juvenile Painted terrapins produced by ex situ incubation, and captive non-breeding adults. Endoscopy of the gonads is a useful techniques for gender determination among juvenile turtles, while the use of testosterone as a gender biomarker warrants further investigation.

A Review of Modern Radiation Therapy Dose Escalation in Locally Advanced Head and Neck Cancer.

The management of head and neck cancer is complex and often involves multimodality treatment. Certain groups of patients, such as those with inoperable or advanced disease, are at higher risk of treatment failure and may therefore benefit from radiation therapy dose escalation. This can be difficult to achieve without increasing toxicity. However, the combination of modern treatment techniques and increased research into the use of functional imaging modalities that assist with target delineation allows researchers to push this boundary further. This review aims to summarise modern dose escalation trials to identify the impact on disease outcomes and explore the growing role of functional imaging modalities. Studies experimenting with dose escalation above standard fractionated regimens as outlined in National Comprehensive Cancer Network guidelines using photon therapy were chosen for review. Seventeen papers were considered suitable for inclusion in the review. Eight studies investigated nasopharyngeal cancer, with the remainder treating a range of subsites. Six studies utilised functional imaging modalities for target delineation. Doses as high as 85.9 Gy in 2.6 Gy fractions (EQD2 90.2 Gy10) were reportedly delivered with the aid of functional imaging modalities. Dose escalation in nasopharyngeal cancer resulted in 3-year locoregional control rates of 86.6-100% and overall survival of 82-95.2%. For other mucosal primary tumour sites, 3-year locoregional control reached 68.2-85.9% and 48.4-54% for overall survival. There were no clear trends in acute or late toxicity across studies, regardless of dose or addition of chemotherapy. However, small cohort sizes and short follow-up times may have resulted in under-reporting. This review highlights the future possibilities of radiation therapy dose escalation in head and neck cancer and the potential for improved target delineation with careful patient selection and the assistance of functional imaging modalities.

The first family group of α1-AT-P in the world with repeated hematomas: 10-year follow-up.

This case report describes the first 10-year follow-up report worldwide of a patient with the genetic variation alpha-1-antitrypsin-Pittsburgh mutation (α1-AT-P). The mutation was confirmed in a 16 year-old Chinese girl after she presented with repeated hematomas, and the mutation with bleeding tendency was also verified in her father. α1-AT-P is a spontaneously occurring autosomal dominant point mutation of α1-antitrypsin, in which methionine-358 is substituted by an arginine derivative. α1-AT-P cases are extremely rare, with only eight reported worldwide. Consequently, there is insufficient experience in the diagnosis and treatment of α1-AT-P. We followed up and reviewed the last 10 years of treatment of a young patient who suffered from repeated life-threatening hematomas, underwent emergency surgery five times, and had her ovaries removed in her twenties to avoid ovulation hemorrhage. The purpose of this article is to raise the awareness of α1-AT-P mutation and to improve its prognosis, especially in female patients.

Depression and risk of hip fracture: a systematic review and meta-analysis of cohort studies.

Recently published studies on the association between depression and hip fracture (HF) are inconsistent. Therefore, we performed this meta-analysis with the main aim to clarify the association between depression and HF, and also to identify possible susceptible groups. Relevant literature published until February 2019 was obtained and screened according to established inclusion criteria. Two researchers independently processed quality assessment and data extraction prior to the meta-analysis. Pooled hazard ratios (HRs) with 95%CI (confidence intervals) were calculated. To explore the sources of heterogeneity, subgroup analyses were performed based on study design, study region, NOS scores, follow-up duration, diagnostic criteria, sex, national income level, and adjustments (bone mineral density (BMD), antidepressant, calcium intake, and smoking). Ten studies with 13 estimates, involving 375,438 participants and 4576 HFs, were included. It was found that patients with depression had a higher risk of HF than non-depressed patients (HR = 1.21; 95%CI 1.11-1.31). Sensitivity analysis results show that the association is relatively stable. The studies that were not adjusted for confounders (e.g., antidepressant, BMD, calcium intake, and smoking) had higher overall HR compared to the studies that adjusted for the corresponding confounding factors. HFs are more likely to occur in European and male depression patients. This meta-analysis provided evidence of a modest positive association between depression and the risk of HFs, and the association is stronger in European and male patients. Implementation of practical measures to prevent and treat depression is of great public health significance.

Inactivation of the bacterial pathogens Staphylococcus pseudintermedius and Acinetobacter baumannii by butanoic acid.

AIMS: This study was performed to evaluate the efficacy of butanoic acid against bacterial pathogens including Acinetobacter baumannii and Staphylococcus pseudintermedius. METHODS AND RESULTS: Vegetative bacteria were exposed to butanoic acid in vitro and log reduction was quantified using viable count assays. The maximum (8 and 9) log inactivation was determined by qualitatively assaying for growth/no-growth after a 48-h incubation (37°C). Membrane integrity after exposure to butanoic acid was determined by propidium iodide staining, scanning electron microscopy, membrane depolarization and inductively coupled plasma analysis. Cytosolic pH was measured by 5-(6-)carboxyfluorescein succinimidyl ester. CONCLUSIONS: Inhibitory concentrations of butanoic acid ranged between 11 and 21 mmol l-1 for Gram-positive and Gram-negative species tested. The maximum log reduction of A. baumannii was achieved with a 10-s exposure of 0·50 mol l-1 of butanoic acid. Staphylococcus pseudintermedius required 0·40 mol l-1 of butanoic acid to achieve the same level of reduction in the same time period. Inactivation was associated with membrane permeability and acidification of the cytosol. SIGNIFICANCE AND IMPACT OF THE STUDY: Antibiotic resistance among bacterial pathogens necessitates the utilization of novel therapeutics for disinfection and biological control. These results may facilitate the development of butanoic acid as an effective agent against a broad-spectrum of antibiotic-resistant bacterial pathogens.

Diagnostic value of far-IR water ice features in T Tauri disks.

AIMS: This paper investigates how the far-IR water ice features can be used to infer properties of disks around T Tauri stars and the water ice thermal history. We explore the power of future observations with SOFIA/HIRMES and SPICA's proposed far-IR instrument SAFARI. METHODS: A series of detailed radiative transfer disk models around a representative T Tauri star are used to investigate how the far-IR water ice features at 45 and 63 µm change with key disk properties: disk size, grain sizes, disk dust mass, dust settling, and ice thickness. In addition, a series of models is devised to calculate the water ice emission features from warmup, direct deposit and cooldown scenarios of the water ice in disks. RESULTS: Photodesorption from icy grains in disk surfaces weakens the mid-IR water ice features by factors 4-5. The far-IR water ice emission features originate from small grains at the surface snow line in disks at distance of 10-100 au. Unless this reservoir is missing in disks (e.g. transitional disks with large cavities), the feature strength is not changing. Grains larger than 10 µm do not contribute to the features. Grain settling (using turbulent description) is affecting the strength of the ice features by at most 15%. The strength of the ice feature scales with the disk dust mass and water ice fraction on the grains, but saturates for dust masses larger than 10-4 M⊙ and for ice mantles that increase the dust mass by more than 50%. The various thermal histories of water ice leave an imprint on the shape of the features (crystalline/amorphous) as well as on the peak strength and position of the 45 µm feature. SOFIA/HIRMES can only detect crystalline ice features much stronger than simulated in our standard T Tauri disk model in deep exposures (1 hr). SPICA/SAFARI can detect the typical ice features in our standard T Tauri disk model in short exposures (10 min). CONCLUSIONS: The sensitivity of SPICA/SAFARI will allow the detailed study of the 45 and 63 µm water ice feature in unbiased surveys of T Tauri stars in nearby star forming regions and an estimate of the mass of their ice reservoir. The water ice emission features carry an imprint of the thermal history of the ice and thus can distinguish between various formation and transport scenarios. Amorphous ice at 45 µm that has a much broader and flatter peak could be detected in deep surveys if the underlying continuum can be well characterized and the baseline stability of SAFARI is better than a few percent.

Mycobacterium abscessus: A Rare Cause of Periprosthetic Knee Joint Infection.

A 61-year-old woman with a periprosthetic knee joint infection caused by Mycobacterium abscessus was successfully treated with surgical débridement, multidrug antimicrobial therapy, and staged reimplantation. To the authors' knowledge, this represents the first report of successfully treating this organism after knee arthroplasty. M. abscessus knee infections are rare, and there are no specific guidelines to inform treatment or successful treatment regimens for periprosthetic knee infections. Medical management alone was not successful in this case and hence cannot be recommended. Using a collaborative multidisciplinary approach, including surgical débridement, staged reimplantation, and multidrug antimicrobials, successful eradication of the periprosthetic joint infection caused by M. abscessus was achieved.

Autoimmune blistering disorders in the setting of human immunodeficiency virus infection.

The interplay between immune dysfunction and human immunodeficiency virus (HIV) is complex. Reports of autoimmune disorders including autoimmune bullous disorders (AIBDs) have been increasing in prevalence in the HIV population since the introduction of highly active antiretroviral therapy in 1995. We offer a literature review of clinical experiences in various AIBDs with particular emphasis on therapeutic management as well as a brief overview of the mechanisms that explain the relationship between AIBD and HIV. Because immunosuppressants are first-line therapies for AIBD treatment, careful consideration is warranted when considering management in the HIV population.

Waste-to-biofuel integrated system and its comprehensive techno-economic assessment in wastewater treatment plants.

Combining wastewater treatment and biofuel production is considered the cost-effective way for better waste remediation and lowering the environmental impact for biofuel production. In this study, an innovative integrated system incorporating sludge, scum and centrate treatment and biofuel production was developed. A comprehensive techno-economic analysis was conducted to evaluate the technology and economic feasibility of the integrated system with the consideration of biofuel production, wastewater treatment improvement, tax credits, carbon credit, and coproducts utilization. Benefited from the integrated system that the intermediate byproducts can be used in between the sub-systems, such as the glycerol generated from the scum-to-biodiesel production can be used as an organic carbon for the centrate-to-algae production, the estimated breakeven selling price of the bio-oil ($1.85/gallon) is very close to the 5-year averaged crude oil price. The assessment result showed the payback period and the IRRs of the integrated system are superior in comparison with others.

Cultivation of Chlorella vulgaris in a pilot-scale photobioreactor using real centrate wastewater with waste glycerol for improving microalgae biomass production and wastewater nutrients removal.

To improve nutrients removal from real centrate wastewater and enhance the microalgae biomass production, cultivation of Chlorella vulgaris in lab and a pilot-scale photobioreactor with waste glycerol was studied. The results showed the optimal concentration of the crude glycerol was 1.0gL-1 with the maximum biomass productivity of 460mgL-1d-1 TVS, the maximum lipid content of 27%, the nutrient removal efficiency of all above 86%, due to more balanced C/N ratio. The synergistic relationship between the wastewater-borne bacteria and the microalgae had significant good influence on nutrient removal. In pilot-scale wastewater-based algae cultivation, with 1gL-1 waste glycerol addition, the average biomass production of 16.7gm-2d-1, lipid content of 23.6%, and the removal of 2.4gm-2d-1 NH4+-N, 2.7gm-2d-1 total nitrogen, 3.0gm-2d-1 total phosphorous, and 103.0gm-2d-1 of COD were attained for 34days semi-continuous mode.

Co-cultivation of microalgae in aquaponic systems.

Aquaponics is a sustainable system for the future farming. In aquaponic systems, the nutrient-rich wastewater generated by the fish provides nutrients needed for vegetable growth. In the present study, the role of microalgae of Chlorella sp. in the floating-raft aquaponic system was evaluated for ammonia control. The yields of algal biomass, vegetable, and removal of the key nutrients from the systems were monitored during the operation of the aquaponic systems. When the systems were in full operation, the algae production was about 4.15±0.19g/m2·day (dry basis) which is considered low because the growth conditions are primarily tailored to fish and vegetable production. However, it was found that algae had a positive effect on balancing pH drop caused by nitrifying bacteria, and the ammonia could be controlled by algae since algae prefer for ammonia nitrogen over nitrate nitrogen. The algae are more efficient for overall nitrogen removal than vegetables.

Forced-ferromagnetic state in a Tm2Fe17H5 single crystal.

We report the attainment of the ferromagnetic state in an interstitially modified heavy rare-earth-iron intermetallic compound in an external magnetic field. The starting composition is RE2Fe17, which is the RE-Fe binary richest in iron. We concentrate on the Tm-Fe compound, which is the most sensitive to magnetic field. The maximum possible amount of hydrogen (5 at.H/f.u.) is inserted into a Tm2Fe17 single crystal. We demonstrate that in a magnetic field of 57 T Tm2Fe17H5 reaches the ferromagnetic state with an enviably high polarization of 2.25 T.

A continuous flocculants-free electrolytic flotation system for microalgae harvesting.

High harvesting cost and reusing of post-harvest water are the major challenges in commercial production of microalgae. In this work, a flocculants-free electrolytic flotation harvest process was investigated. The electrode design and materials were evaluated in terms of harvesting efficiency. Stainless steel as the cathode and carbon as the anode were selected based on the harvesting efficiency data and non-sacrificial feature for construction of a pilot scale harvesting system. In the pilot scale experiments, 23.72g/h biomass yield was achieved at the power consumption of 2.73kWh/kg. With the advantages of no chemical flocculent contamination and relatively low energy requirement, this continuous system is promising for food or feed applications.

Correlation analysis of mast cells and EGFR with endoscopic application of tissue glue for treatment of peptic ulcer healing.

OBJECTIVE: To investigate the impact of tissue glue on mast cells (MC) and epidermal growth factor receptor (EGFR) in rat peptic ulcer. MATERIALS AND METHODS: SD rats were used to establish peptic ulcer model. Cimetidine gavage was adopted in the positive control, while cimetidine and endoscopic tissue glue therapy were applied in the experimental group. The ulcer inhibition rate and ulcer index were measured to evaluate healing quality. Real-time PCR was performed to test EGFR mRNA in the ulcer surrounded gastric mucosa. Immunohistochemistry was selected to determine MC quantity. HE staining and apoptosis detection were used to evaluate cell apoptosis. RESULTS: Tissue glue significantly reduced MC number in the peptic ulcer rat compared with control with dose dependence (p < 0.05). Tissue glue significantly decreased ulcer area, and elevated ulcer index and inhibition rate (p < 0.05). EGFR mRNA in the mucosa markedly declined after modeling. Tissue glue upregulated EGFR mRNA to a certain extent (p > 0.05). Tissue glue induced MC apoptosis with dose dependence. CONCLUSIONS: Endoscopic application of tissue glue accelerated ulcer mucosa healing via up-regulating EGFR mRNA, enhancing gastrointestinal mucous membrane regeneration and repair ability, and decreasing MC number.

[Experience of low calcium crisis after the operation in peritonea dialysis secondary].

We report a case of secondary hyperparathyroidism after peritoneal dialysis. After given the total parathyroidectomy and forearm autoplantation (PTX+AT), the patient presented with an acute low calcium crisis (tongue myoparalysis, tetany and ECG abnormalities). As the conventional calcium treatment was invalid, the calcium solution was then changed, and replaced by the standard calcium dialysate with monitoring calcium ions. At the last, the patient was rescued. After a long term followed up, the patient's clinical symptoms were improved, and the parathyroid hormone (iPTH) level basically kept within the scope of the KDIGO guidelines.

[Recent advances in early diagnosis of head and neck cancer in precision medicine era].

Head and neck squamous cell carcinoma, HNSCC, has high morbidity and mortality. Even in America, more than 1/2 to 2/3 patients have been diagnosed at advanced stage. So, it's urgent to find ways to diagnose HNSCC earlier and foresee the curative effect. With the achievement of Next-Generation Sequencing, researchers are trying to develop early diagnostic technology from a new perspective, such as personal genomics, proteomics, metabolomics and other related personal information. Here we reviewed the recent research in early diagnosis of HNSCC.