Acute kidney injury in the critical care setting.

Acute kidney injury is a sudden reduction in renal function which impairs the kidneys' ability to maintain fluid, electrolyte and acid-base balance. The syndrome often develops secondary to severe illness and is associated with a significant increase in morbidity and mortality rate in critically ill patients. This article gives an overview of the pathophysiology and aetiology of acute kidney injury, as well as the associated complications and clinical diagnostic signs. The authors also describe some common causes of the syndrome in critically ill patients, specifically sepsis, liver failure and cardiac failure, and discuss patient management in the critical care setting, with a focus on haemodynamic support and continuous renal replacement therapy.

Adult liver transplantation for the advanced clinical practitioner: an overview.

Liver transplantation (LT) is a major surgical undertaking but, in a carefully selected population, it provides excellent outcomes in terms of prolongation of life and improvements in quality of life. This article outlines the processes of referral, assessment, operative course and post-transplant complications of LT, in the UK context. Specific consideration is also given to immunosuppressive medications and considerations around their prescription. The role of the advanced clinical practitioner (ACP) in primary or secondary care may focus on identifying potential candidates for transplantation and ensuring timely discussion and referral. Thus, a familiarity with eligibility criteria, and where to access this information, is important for all ACPs. Additionally, the increasing numbers of transplants performed in the UK mean that there is a large population of post-transplant patients in the wider community. These patients may present to healthcare services with a variety of issues relating to their LT, where early recognition and treatment has the potential to have major impacts on patient, or graft, function and longevity. Due to this, early discussions with specialist transplant centres is advised.

Critical thinking and diagnostic reasoning for advanced clinical practitioners in sexual health.

This article provides an overview of key areas within sexual health examination, diagnosis and treatment options for advanced clinical practitioners (ACPs) working outside this field of practice, who may not often encounter consultations of a sexual health nature. ACPs require an understanding of appropriate and necessary investigations, alongside specific advice or education they can offer patients. Within a sexual health context especially, the consultation and subsequent steps can be challenging and distressing for the patient, and the ACP must consider their knowledge and experience when caring for a patient in this area. Increasing knowledge and awareness of common conditions and treatments, red flags, and referral processes can allow the ACP to provide reassurance and support to the patient and improve their healthcare experience. Having answers to a patient's questions regarding processes and time frames can strengthen the relationship between the ACP and their patient and help reduce a patient's anxiety and fear of the unknown.

Consultation and clinical assessment for advanced clinical practitioners in sexual health.

Sexual health is a very important aspect of patient wellbeing, but it is a topic health professionals still find challenging within patient consultations. The incidence of sexually transmitted infections (STIs) continues to rise, highlighting the need for all advanced clinical practitioners (ACPs) to understand the principles of a sexual health consultation as they may have to support patients who present with a sexual health concern, not purely those in specialist clinics and roles. This article provides a comprehensive overview of key points to include as part of a consultation and assessment within this area of specialist practice. Effective communication is a key skill for obtaining a thorough, clear history, allowing for more accurate differentials and a smoother patient journey. The environment and body language are two other considerations when undertaking a sexual health consultation. As with all histories, a systematic approach is essential and having a solid knowledge of the foundations of sexual health will enable the ACP to focus this history to obtain pertinent information.

Chronic kidney disease and renal replacement therapy: an overview for the advanced clinical practitioner.

Chronic kidney disease (CKD), also known as chronic renal failure (CRF), is a common, globally significant condition, with associated significant mortality and morbidity. Due to the disease prevalence, advanced clinical practitioners (ACPs) in a variety of primary and secondary care settings will encounter patients with this diagnosis who will require care and treatment. This article examines definitions of CKD, describes a clinical approach to a patient with CKD, including key history and examination findings, and provides a brief overview of renal replacement strategies for the patient with end-stage renal failure. ACPs require a thorough understanding of this condition and the key elements of treatment and care in this population.

Critical thinking and diagnostic reasoning when advanced practitioners assess and treat skin conditions.

Advanced clinical practitioner (ACP) roles require a broad range of knowledge of both medical and surgical medicine and the ability to work autonomously in a variety of settings. Despite around half of the UK adult population presenting with a skin condition requiring attention, this is something many ACPs feel unprepared to be consulted on. However, due to the complexity and large number of potential diagnoses, it is imperative that ACPs develop their confidence and knowledge to diagnosis, request investigations and initiate treatment for a patient with a skin complaint. In the first part of this clinical review the authors presented the key elements of history taking, consultation and assessment of the skin. This second clinical review discusses the main differential diagnoses, mimics, common investigations and treatments. This article is designed to support novice ACPs from acute hospital settings to primary care to develop a foundation of understanding in the main diagnosis and treatment options that should be considered following a clinical assessment of patients' skin outside the dermatology setting.

Conducting a consultation and clinical assessment of the skin for advanced clinical practitioners.

Advanced clinical practitioner (ACP) roles require a broad range of knowledge of both medical and surgical areas and the ability to work autonomously in a variety of settings. Despite around half of the UK adult population presenting with a skin condition requiring attention at some point, this is an area many ACPs feel unprepared to manage. However, due to the complexity and large number of potential diagnoses, it is imperative that ACPs develop their knowledge of skin conditions so that they can confidently conduct consultations with patients. This clinical review presents the key elements of patient consultation, history taking and assessment of the skin. This is designed to support novice ACPs, whether working in acute hospital settings or primary care, to develop an understanding of the key points that should be included when consulting with and assessing the skin of patients outwith the dermatology setting.

Neurophysiological improvements in speech-in-noise task after short-term choir training in older adults.

Perceiving speech in noise (SIN) is important for health and well-being and decreases with age. Musicians show improved speech-in-noise abilities and reduced age-related auditory decline, yet it is unclear whether short term music engagement has similar effects. In this randomized control trial we used a pre-post design to investigate whether a 12-week music intervention in adults aged 50-65 without prior music training and with subjective hearing loss improves well-being, speech-in-noise abilities, and auditory encoding and voluntary attention as indexed by auditory evoked potentials (AEPs) in a syllable-in-noise task, and later AEPs in an oddball task. Age and gender-matched adults were randomized to a choir or control group. Choir participants sang in a 2-hr ensemble with 1-hr home vocal training weekly; controls listened to a 3-hr playlist weekly, attended concerts, and socialized online with fellow participants. From pre- to post-intervention, no differences between groups were observed on quantitative measures of well-being or behavioral speech-in-noise abilities. In the choir group, but not the control group, changes in the N1 component were observed for the syllable-in-noise task, with increased N1 amplitude in the passive condition and decreased N1 latency in the active condition. During the oddball task, larger N1 amplitudes to the frequent standard stimuli were also observed in the choir but not control group from pre to post intervention. Findings have implications for the potential role of music training to improve sound encoding in individuals who are in the vulnerable age range and at risk of auditory decline.

Designing and developing core physiology learning outcomes for pre-registration nursing education curriculum.

Physiology is a key element of "bioscience" education within pre-registration nursing programs, but there is a lack of clarity on what is included. Physiology and bioscience content and delivery are highly varied across both higher education institutions and the related programs in the United Kingdom (UK). Despite evidence highlighting concerns over nurses' lack of bioscience knowledge and unsafe practice, there is no universally agreed on curriculum with detailed outcomes of minimum levels of knowledge to support nurses in practice and patient care. This study aimed to inform the construction of discipline-specific physiology learning outcomes to clarify relevant physiological topics required in pre-registration nursing. Initially, 360 learning outcomes were identified from various sources. Using a modified Delphi approach, an expert panel from the Bioscience in Nurse Education group reviewed and modified the list to 195 proposed outcomes. These were circulated to universities in the UK who teach nursing (n = 65). Outcomes that had 80% consensus were automatically included in the next round, with others recommended with modification (response rate 22%). The panel reviewed the modifications, and 182 outcomes were circulated in the second questionnaire (response rate 23%), and further panel review resulting in 177 outcomes agreed. These learning outcomes do not suggest how they should be delivered, but gives the basic level required for qualification as a nurse commensurate with the Nursing and Midwifery Council new standards for the "future nurse."

The (p)ppGpp-binding GTPase Era promotes rRNA processing and cold adaptation in Staphylococcus aureus.

Ribosome assembly cofactors are widely conserved across all domains of life. One such group, the ribosome-associated GTPases (RA-GTPase), act as molecular switches to coordinate ribosome assembly. We previously identified the Staphylococcus aureus RA-GTPase Era as a target for the stringent response alarmone (p)ppGpp, with binding leading to inhibition of GTPase activity. Era is highly conserved throughout the bacterial kingdom and is essential in many species, although the function of Era in ribosome assembly is unclear. Here we show that Era is not essential in S. aureus but is important for 30S ribosomal subunit assembly. Protein interaction studies reveal that Era interacts with the 16S rRNA endonuclease YbeY and the DEAD-box RNA helicase CshA. We determine that both Era and CshA are required for growth at suboptimal temperatures and rRNA processing. Era and CshA also form direct interactions with the (p)ppGpp synthetase RelSau, with RelSau positively impacting the GTPase activity of Era but negatively affecting the helicase activity of CshA. We propose that in its GTP-bound form, Era acts as a hub protein on the ribosome to direct enzymes involved in rRNA processing/degradation and ribosome subunit assembly to their site of action. This activity is impeded by multiple components of the stringent response, contributing to the slowed growth phenotype synonymous with this stress response pathway.

Delivering direct patient care in the haemodialysis unit: a focused ethnographic study of care delivery.

BACKGROUND: Direct patient care is a term used within nursing and healthcare to help quantify and qualify care delivery. Direct patient care time is considered as a valuable measure by healthcare providers to indicate efficiency and to quantify nursing work, however little is understood of the patient experience and care delivery in haemodialysis settings. AIM: The aim of this study was to gain an understanding of patients' and nursing staff perceptions and experiences of 'direct patient care' within one haemodialysis unit. METHODS: A focused ethnographic approach utilised participant observations, informal questioning, photographs and 27 semi-structured interviews of registered nurses, clinical support workers and patients. Observation notes and interviews were transcribed and thematically analysed. RESULTS: The key finding was the construction and reconceptualisation of care delivery in this setting. Care was identified to be delivered in two distinct ways, both of which allowed patients to feel cared for. 'Active care' where patients feel cared for when they are being dealt with directly by staff and 'Passive care' where patients feel cared for through staff availability and visibility. CONCLUSION: Developing this understanding of patient care delivery in this specialism has highlighted some important aspects to the way care can be delivered which challenges current traditional understandings of direct patient care. Time spent with a patient is not the only important consideration to patient experience in haemodialysis. This understanding of passive care could improve care experiences in this setting.

Functional analysis of the Helicobacter pullorum N-linked protein glycosylation system.

N-linked protein glycosylation systems operate in species from all three domains of life. The model bacterial N-linked glycosylation system from Campylobacter jejuni is encoded by pgl genes present at a single chromosomal locus. This gene cluster includes the pglB oligosaccharyltransferase responsible for transfer of glycan from lipid carrier to protein. Although all genomes from species of the Campylobacter genus contain a pgl locus, among the related Helicobacter genus only three evolutionarily related species (H. pullorum, H. canadensis and H. winghamensis) potentially encode N-linked protein glycosylation systems. Helicobacter putative pgl genes are scattered in five chromosomal loci and include two putative oligosaccharyltransferase-encoding pglB genes per genome. We have previously demonstrated the in vitro N-linked glycosylation activity of H. pullorum resulting in transfer of a pentasaccharide to a peptide at asparagine within the sequon (D/E)XNXS/T. In this study, we identified the first H. pullorum N-linked glycoprotein, termed HgpA. Production of histidine-tagged HgpA in the background of insertional knockout mutants of H. pullorum pgl/wbp genes followed by analysis of HgpA glycan structures demonstrated the role of individual gene products in the PglB1-dependent N-linked protein glycosylation pathway. Glycopeptide purification by zwitterionic-hydrophilic interaction liquid chromatography coupled with tandem mass spectrometry identified six glycosites from five H. pullorum proteins, which was consistent with proteins reactive with a polyclonal antiserum generated against glycosylated HgpA. This study demonstrates functioning of a H. pullorum N-linked general protein glycosylation system.

Cost, energy, global warming, eutrophication and local human health impacts of community water and sanitation service options.

We compared water and sanitation system options for a coastal community across selected sustainability metrics, including environmental impact (i.e., life cycle eutrophication potential, energy consumption, and global warming potential), equivalent annual cost, and local human health impact. We computed normalized metric scores, which we used to discuss the options' strengths and weaknesses, and conducted sensitivity analysis of the scores to changes in variable and uncertain input parameters. The alternative systems, which combined centralized drinking water with sanitation services based on the concepts of energy and nutrient recovery as well as on-site water reuse, had reduced environmental and local human health impacts and costs than the conventional, centralized option. Of the selected sustainability metrics, the greatest advantages of the alternative community water systems (compared to the conventional system) were in terms of local human health impact and eutrophication potential, despite large, outstanding uncertainties. Of the alternative options, the systems with on-site water reuse and energy recovery technologies had the least local human health impact; however, the cost of these options was highly variable and the energy consumption was comparable to on-site alternatives without water reuse or energy recovery, due to on-site reuse treatment. Future work should aim to reduce the uncertainty in the energy recovery process and explore the health risks associated with less costly, on-site water treatment options.

Incentivizing Decentralized Sanitation: The Role of Discount Rates.

In adoption decisions for decentralized sanitation technologies, two decision makers are involved: the public utility and the individual homeowner. Standard life cycle cost is calculated from the perspective of the utility, which uses a market-based discount rate in these calculations. However, both decision-makers must be considered, including their differing perceptions of the time trade-offs inherent in a stream of costs and benefits. This study uses the discount rate as a proxy for these perceptions and decision-maker preferences. The results in two case studies emphasize the dependence on location of such analyses. Falmouth, Massachusetts, appears to be a good candidate for incentivizing decentralized sanitation while the Allegheny County Sanitary Authority service area in Pennsylvania appears to have no need for similar incentives. This method can be applied to any two-party decision in which the parties are expected to have different discount rates.

ppGpp negatively impacts ribosome assembly affecting growth and antimicrobial tolerance in Gram-positive bacteria.

The stringent response is a survival mechanism used by bacteria to deal with stress. It is coordinated by the nucleotides guanosine tetraphosphate and pentaphosphate [(p)ppGpp], which interact with target proteins to promote bacterial survival. Although this response has been well characterized in proteobacteria, very little is known about the effectors of this signaling system in Gram-positive species. Here, we report on the identification of seven target proteins for the stringent response nucleotides in the Gram-positive bacterium Staphylococcus aureus We demonstrate that the GTP synthesis enzymes HprT and Gmk bind with a high affinity, leading to an inhibition of GTP production. In addition, we identified five putative GTPases--RsgA, RbgA, Era, HflX, and ObgE--as (p)ppGpp target proteins. We show that RsgA, RbgA, Era, and HflX are functional GTPases and that their activity is promoted in the presence of ribosomes but strongly inhibited by the stringent response nucleotides. By characterizing the function of RsgA in vivo, we ascertain that this protein is involved in ribosome assembly, with an rsgA deletion strain, or a strain inactivated for GTPase activity, displaying decreased growth, a decrease in the amount of mature 70S ribosomes, and an increased level of tolerance to antimicrobials. We additionally demonstrate that the interaction of ppGpp with cellular GTPases is not unique to the staphylococci, as homologs from Bacillus subtilis and Enterococcus faecalis retain this ability. Taken together, this study reveals ribosome inactivation as a previously unidentified mechanism through which the stringent response functions in Gram-positive bacteria.

PRECiS (Patient Reported Evaluation of Cognitive State): psychometric evaluation of a new patient reported outcome measure of the impact of stroke.

OBJECTIVE: Determine the psychometric properties of PRECiS (Patient Reported Evaluation of Cognitive State): A new patient-centred, patient reported outcome measure for perceived impact of cognitive problems, developed through qualitative work, systematic review and service user consultation. DESIGN: An observational study exploring acceptability, internal consistency, construct validity, inter-rater reliability and test-retest reliability, with opportunistic qualitative data on sensitivity to change. SETTING: Home visits in the community. PARTICIPANTS: Stroke survivors with self-reported cognitive difficulties and informal carers. MEASURES: The 27 item PRECiS was self-completed with support, and proxy completed by informal carers. We collected descriptive cognitive screening test data, and measures of overall stroke impact, mood and activities of daily living to explore construct validity. RESULTS: Data were collected from 159 (visit 1) and 66 (visit 2) stroke survivors and 86 informal carers. PRECiS showed good acceptability (no missing values or floor/ceiling effects, minimal skewness); high internal consistency (α = 0.94, indicative of potential redundancy); with moderate to strong construct correlations in the directions hypothesised (0.40 to 0.74). An intraclass correlation coefficient of 0.85 indicated good test-retest reliability. Where self-reported change had occurred from visit 1 to 2, PRECiS appeared sensitive. Using carers as proxy respondents is not supported by this analysis (inter-rater ICC = 0.43). CONCLUSIONS: PRECiS is a patient-centred, practical and reliable measure assessing perceived impact of cognitive problems from the unique perspective of stroke survivors.