A Quality Improvement Initiative to Reduce the Frequency of Delays in Initiation and Restarts of Continuous Renal Replacement Therapy.

BACKGROUND: Continuous renal replacement therapy (CRRT) is a lifesaving intervention for critically ill patients. Delays in initiation, or an inability to resume CRRT following a temporary suspension in therapy (CRRT restart), can result in suboptimal CRRT delivery. LOCAL PROBLEM: Intensive care units across the health care system were experiencing significant delays in CRRT initiation and restarts. APPROACH: A multimodal quality improvement initiative was implemented across 7 adult intensive care units, which allowed unit-based staff nurses to initiate and restart CRRT, a task that had previously been delegated to non-unit-based dialysis nurses. OUTCOMES: A 75% reduction in CRRT initiation delays and a 90% reduction in CRRT restart delays were observed in the 12 months following the initiative. There were no adverse events or increased disposable CRRT circuit usage following the initiative. CONCLUSIONS: Implementation of CRRT initiation and restarts by unit-based nurses were achievable and resulted in substantial improvements in timeliness of CRRT delivery.

Species composition of coastal dune vegetation in Scotland has proved resistant to climate change over a third of a century.

Climate change is expected to have an impact on plant communities as increased temperatures are expected to drive individual species' distributions polewards. The results of a revisitation study after c. 34 years of 89 coastal sites in Scotland, UK, were examined to assess the degree of shifts in species composition that could be accounted for by climate change. There was little evidence for either species retreat northwards or for plots to become more dominated by species with a more southern distribution. At a few sites where significant change occurred, the changes were accounted for by the invasion, or in one instance the removal, of woody species. Also, the vegetation types that showed the most sensitivity to change were all early successional types and changes were primarily the result of succession rather than climate-driven changes. Dune vegetation appears resistant to climate change impacts on the vegetation, either as the vegetation is inherently resistant to change, management prevents increased dominance of more southerly species or because of dispersal limitation to geographically isolated sites.

Dichorionic Diamniotic Twin Anencephaly and Exencephaly.

We present a rare case of dichorionic diamniotic twin anencephaly and exencephaly discovered in a 35-year-old female at 13.1 weeks of gestation. Anencephaly and exencephaly are neural tube defects (NTD) with devastating consequences caused by the failure of the anterior neural groove closure leading to exencephaly, followed by brain disintegration causing anencephaly. While NTD themselves are common congenital anomalies, their presence in both twins of a dichorionic diamniotic gestation is exceedingly rare and has only been documented in one other instance. The uncertainty surrounding risk factors involved in this specific case underscores the importance of ongoing research to elucidate other potential determinants in the pathogenesis of NTD and to discover novel preventive strategies, particularly in twin pregnancies. Future research endeavors should explore the interplay of genetic, environmental, and other anomalous factors to deepen our understanding and improve clinical outcomes for affected pregnancies.

Clinical, imaging, and intervention factors associated with the upgrade of isolated flat epithelial atypia.

PURPOSE: This study aims to determine clinical, imaging, and intervention factors associated with the upgrade of flat epithelial atypia (FEA) diagnosed on vacuum-assisted biopsy (VAB) in order to formulate criteria for excision and better assist in management. METHODS: Between 2012 and 2015, 254 patients had a form of atypia diagnosed on ultrasound, MRI or stereotactic VAB and met eligibility for this study. Demographic, imaging, biopsy and pathology characteristics were analyzed for association with upgrade. We compared isolated FEA to all of the atypias grouped together. RESULTS: Of the 254 atypia lesions, 72 (28%) were isolated FEA, and the upgrade rate was 2.8% (2/72). Statistically significant factors present with upgrade of isolated FEA include personal history of breast cancer and cancer diagnosis on a concurrent separate core biopsy. Other factors associated with upgrade include first degree family history of breast cancer, segmental calcification distribution, extent of calcifications >2 cm, and <25% of calcifications removed on biopsy. CONCLUSION: In patients with biopsy results of isolated FEA, in the absence of personal or first degree family history of breast cancer, cancer on a concurrent biopsy, segmental calcification distribution, extent of calcifications >2 cm, and only 0-24% calcifications removed on biopsy, patients may be safely followed with imaging, avoiding unnecessary excision.

Long-term impacts of nitrogen deposition on coastal plant communities.

Nitrogen deposition has been shown to have significant impacts on a range of vegetation types resulting in eutrophication and species compositional change. Data from a re-survey of 89 coastal sites in Scotland, UK, c. 34 years after the initial survey were examined to assess the degree of change in species composition that could be accounted for by nitrogen deposition. There was an overall increase in the Ellenberg Indicator Value for nitrogen (EIV-N) of 0.15 between the surveys, with a clear shift to species characteristic of more eutrophic situations. This was most evident for Acid grassland, Fixed dune, Heath, Slack and Tall grass mire communities and despite falls in EIV-N for Improved grass, Strand and Wet grassland. The increase in EIV-N was highly correlated to the cumulative deposition between the surveys, and for sites in south-east Scotland, eutrophication impacts appear severe. Unlike other studies, there appears to have been no decline in species richness associated with nitrogen deposition, though losses of species were observed on sites with the very highest levels of SOx deposition. It appears that dune vegetation (specifically Fixed dune) shows evidence of eutrophication above 4.1 kg N ha(-1) yr(-1), or 5.92 kg N ha(-1) yr(-1) if the lower 95% confidence interval is used. Coastal vegetation appears highly sensitive to nitrogen deposition, and it is suggested that major changes could have occurred prior to the first survey in 1976.

An intra-abdominal abscess or "rind" as a consequence of peritoneal dialysis-associated pseudomonas peritonitis.

BACKGROUND: Abdominal CT imaging has defined characteristics of two pathological entities specific to peritoneal dialysis patients. Both are associated with serious peritoneal complications. One is comprised of ascites accompanied by septation and loculated fluid pockets as a complication of bacterial peritonitis. The other is the syndrome of encapsulating peritoneal sclerosis. We present the evolution of a single, thick-walled fluid collection as a consequence of relapsing Pseudomonas aeruginosa peritonitis. The entity had distinctive features differing from either of the two previously described entities, and to our knowledge, has not been described previously. Our patient's radiological evolution resembled the formation of a pleural or peritoneal "rind." CONCLUSION: Peritonitis, as a result of Pseudomonas aeruginosa, may lead to "rind" formation as described with empyemas and is distinct from previously described intra-abdominal pathologies in peritoneal dialysis patients.

Selective and antagonistic functions of SWI/SNF and Mi-2beta nucleosome remodeling complexes during an inflammatory response.

Studies of mammalian genes activated in response to an acute stimulus have suggested diverse mechanisms through which chromatin structure and nucleosome remodeling events contribute to inducible gene transcription. However, because of this diversity, the logical organization of the genome with respect to nucleosome remodeling and gene induction has remained obscure. Numerous proinflammatory genes are rapidly induced in macrophages in response to microbial infection. Here, we show that in lipopolysaccharide-stimulated macrophages, the catalytic BRG1/BRM subunits of the SWI/SNF class of ATP-dependent nucleosome remodeling complexes are consistently required for the activation of secondary response genes and primary response genes induced with delayed kinetics, but not for rapidly induced primary response genes. Surprisingly, a Mi-2beta complex was selectively recruited along with the SWI/SNF complexes to the control regions of secondary response and delayed primary response genes, with the Mi-2beta complex acting antagonistically to limit the induction of these gene classes. SWI/SNF and Mi-2beta complexes influenced cell size in a similarly antagonistic manner. These results provide insight into the differential contributions of nucleosome remodeling complexes to the rapid induction of defined classes of mammalian genes and reveal a robust anti-inflammatory function of Mi-2beta.