Examining perceptions from in situ simulation-based training on interprofessional collaboration during crisis event management in post-anesthesia care.

Due to the potentially life-threatening conditions and risk of severe complications, post-anesthesia care units (PACU) require prompt team interventions. Miscommunication among professionals during crisis event management may directly affect patient safety. Therefore, developing strategies to enhance interprofessional collaboration (IPC) among critical care teams should be prioritized. In situ simulation (ISS) can be valuable in improving patient safety because it allows the practice of care team dynamics within a real clinical environment. However, its impact on IPC has yet to be demonstrated. The aim of this study was to evaluate the effect of in situ simulation-based training on interprofessional collaboration and satisfaction toward co-workers during crisis event management in post-anesthesia care. A quasi-experimental study, pretest and post-test design with a paired control group was performed. A convenience sample (N = 69) was recruited from the healthcare professionals of the regular PACU team. The intervention group (N = 33) underwent a 6-hour ISS-based interprofessional training session. Three scenarios of deteriorating cases encountered in critical care settings were used, each followed by a debriefing period. The measured outcomes were evaluated by the Collaborative Work Questionnaire and the Satisfaction Towards Coworkers Questionnaire. Questionnaires were answered by the two groups before the intervention (T1), immediately after (T2) and six to eight weeks later (T3). We found that the change from baseline (T1) was different between the groups for global IPC (F = 3.88; p = 0.025) and for communication (F = 4.09; p = 0.021). Regarding global IPC, we observed a significant group effect from T1 to T2 (F = 5.65; p = 0.021) and from T1 to T3 (F = 5.34; p = 0.024). Furthermore, we observed a significant time effect for the experimental group (F = 4.06; p = 0.027). Regarding communication, we observed a significant group effect from T1 to T2 (F = 7.5; p = 0.001). In conclusion, ISS-based training had a slight impact on self-assessed IPC and communication during crisis event management in the PACU. The use of ISS should be promoted among critical care teams to enhance IPC and contribute to patient safety.

Tabalumab in rheumatoid arthritis patients with an inadequate response to methotrexate and naive to biologic therapy: a phase II, randomized, placebo-controlled trial.

OBJECTIVE: Tabalumab, a fully human IgG4 monoclonal antibody, neutralizes soluble and membrane-bound BAFF. The aim of this study was to examine the tolerability and efficacy of tabalumab in patients with active rheumatoid arthritis receiving methotrexate. METHODS: In this randomized, double-blind, placebo-controlled, parallel, multiple-dose study, patients who were naive to biologic therapy received infusions of tabalumab (30, 60, or 160 mg) or placebo at weeks 0, 3, and 6 in combination with methotrexate and were evaluated for 24 weeks. The primary efficacy end point was the percentage of patients meeting American College of Rheumatology 20% improvement criteria (achieving an ACR20 response) at week 16. RESULTS: At week 16, the percentages of patients achieving an ACR20 response in the 30-mg (57.6%), 60-mg (67.6%), and 160-mg (51.5%) groups were significantly greater than the percentage of patients achieving an ACR20 response in the placebo group (29.4%; P<0.05). There were initial transient increases from baseline in the frequency of CD20+ and IgD+/CD27- B cells, followed by reductions, although B cells were not completely depleted. Also, the frequency of IgD-/CD27+ B cells increased in all tabalumab groups compared with the placebo group and returned toward baseline levels by the end of the study. The incidence of adverse events was similar across all treatment groups; no deaths occurred. Serum IgM levels decreased significantly in all tabalumab groups combined compared with the placebo group. There were no significant decreases in serum IgG or IgA levels in the tabalumab groups compared with the placebo group. CONCLUSION: Tabalumab treatment significantly reduces the signs and symptoms of rheumatoid arthritis and has a safety profile similar to that seen with placebo treatment.

Spatio-Temporal Pattern of Tuberculosis Distribution in Romania and Particulate Matter Pollution Associated With Risk of Infection.

The study proposes a dynamic spatio-temporal profile of the distribution of tuberculosis incidence and air pollution in Romania, where this infectious disease induces more than 8,000 new cases annually. The descriptive analysis for the years 2012-2021 assumes an identification of the structuring patterns of mycobacterium tuberculosis risk in the Romanian population, according to gender and age, exploiting spatial modeling techniques of time series data. Through spatial autocorrelation, the degree of similarity between the analyzed territorial systems was highlighted and the relationships that are built between the analysis units in spatial proximity were investigated. By modeling the geographical distribution of tuberculosis, the spatial correlation with particulate matter (PM2.5) pollution was revealed. The identification of clusters of infected persons is an indispensable step in the construction of efficient tuberculosis management systems. The results highlight the link between the distribution of tuberculosis, air pollution and socio-economic development, which requires a detailed analysis of the epidemiological data obtained in the national tuberculosis surveillance and control program from the perspective of geographical distribution.

Using High-Fidelity Simulation to Teach Ethics Related Non-Technical Skills: Description of an Innovative Model.

This article describes a high-fidelity (Hi-Fi) simulation-based innovative educational strategy intended to introduce anesthesiology residents to key ethical considerations and how they apply to their practice. Three Hi-Fi simulation scenarios involving situations with various ethical issues are described with their debriefing objectives and the trainees' subjective feedback. Three high-fidelity simulation scenarios are described: (a) teaching critical incident disclosure, (b) disclosing and discussing patient awareness during general anesthesia, and (c) would physicians override a do-not-resuscitate (DNR) order if the cause of a cardiac arrest is iatrogenic? We used Hi-Fi simulation in an innovative way to teach these principles of ethics. Simulation, through carefully crafted debriefing, can contribute to the acquisition of essential non-technical ethical skills. How best to integrate simulation in an existent ethics curriculum and how it compares with more traditional teaching methods are questions that need to be addressed.

Interleukin-10 promotes activation-induced cell death of SLE lymphocytes mediated by Fas ligand.

Immune function in SLE is paradoxically characterized by active T cell help for autoantibody production, along with impaired T cell proliferative and cytokine responses in vitro. To reconcile these observations, we investigated the possibility that the accelerated spontaneous cell death of SLE lymphocytes in vitro is caused by an activation-induced cell death process initiated in vivo. 27 SLE patients, three patients with systemic vasculitis, seven patients with arthritis, and 14 healthy subjects were studied. Patients with clinically active SLE or systemic vasculitis had accelerated spontaneous death of PBMC with features of apoptosis at day 5 of culture. A prominent role for IL-10 in the induction of apoptosis was observed, as neutralizing anti-IL-10 mAb markedly reduced cell death in the active SLE patients by 50%, from 22.3 +/- 5.2% to 11.2 +/- 2.8%, and the addition of IL-10 decreased viability in the active SLE group, but not in the control group, by 38%. In addition, apoptosis was shown to be actively induced through the Fas pathway. The potential clinical relevance of T cell apoptosis in active SLE is supported by the correlation of increased apoptosis and IL-10 levels in vitro with low lymphocyte counts in vivo. We conclude that the spontaneous cell death observed in vitro in lymphocytes from patients with SLE and other systemic autoimmune disorders results from in vivo T cell activation, is actively induced by IL-10 and Fas ligand, and reflects pathophysiologically important events in vivo. Activation-induced cell death in vivo provides a pathogenic link between the aberrant T helper cell activation and impaired T cell function that are characteristic features of the immune system of patients with SLE.

An integrative review of in situ simulation training: Implications for critical care nurses.

BACKGROUND: In situ simulation (ISS) is an emerging teaching strategy aimed to improve professionals' competencies and collaborative practice to increase patient safety The impact of ISS is still to be demonstrated before expanding the use of this method in our critical care settings. PURPOSE: The objective of this paper is to explore the literature regarding ISS training and present advantages and challenges. DESIGN AND METHOD: An integrative review was conducted, based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Online databases MEDLINE and CINAHL were searched. The main keywords used were "in situ simulation", "communication" and "interdisciplinary". We excluded studies conducted outside of the hospital or the clinic, single case studies and framework analyses. FINDINGS: Twenty-eight articles were reviewed. Studies were mainly descriptive and exploratory. They underlined the advantages and challenges of the ISS training regarding safety, as well as the perspectives of patients, families, health care providers and administrators. CONCLUSION AND NURSING IMPLICATIONS: Although ISS is a promising educational strategy to increase patient safety, there is still a need for higher evidence level research to support its efficacy to improve competencies. With regard to patient safety improvement, ISS-based training offers opportunities to identify hazards and deficiencies of clinical systems and the provider team. Experimental studies are necessary to increase evidence about the impact of ISS training.

Lymphoma in patients with rheumatoid arthritis: association with the disease state or methotrexate treatment.

Although long-term clinical studies have shown no excessive risk of lymphoma in rheumatoid arthritis (RA) patients treated with methotrexate (MTX), an increasing number of reports of this association continue to appear. We describe two cases, review the cases in the world's literature, and summarize their important characteristics. Possible oncogenic mechanisms are discussed. Most lymphoproliferation cases presented here have features of immunosuppression-associated lymphoma. The immunosuppressed state is attributable to a combination of factors, such as RA itself and the actions of MTX. The risk factors for RA patients to develop lymphoma while on MTX include severe disease, intense immunosuppression, genetic predisposition, and an increased frequency of latent infection with prooncogenic viruses such as Epstein-Barr virus (EBV). The spontaneous remission of lymphomas in eight RA patients after MTX was stopped highlights the likely causative role of the drug in the development of these malignancies. If the clinical situation permits, a period of observation for spontaneous remission after MTX is stopped is advisable. The physicians caring for RA patients on MTX should maintain a high surveillance for signs and symptoms suggestive of lymphoma.

Anti-P antibodies and neuropsychiatric lupus erythematosus.

A high proportion of patients with SLE develop neuropsychiatric lupus during the course of their disease. The expression of disease varies significantly in terms of clinical manifestations, onset, and severity, so that this form of lupus remains a major diagnostic and therapeutic challenge. Because affected tissue cannot be sampled and animal models are not readily available, scientific investigation is considerably hampered. Approximately 15% of lupus patients have anti-P antibodies. These autoantibodies are highly specific for SLE. Most series show a highly significant association between anti-P and lupus psychosis, and this result is now confirmed in a series of 336 SLE patients. The mechanism explaining this association is uncertain and may simply reflect an immune response to damaged tissue. However, the possibility that the antibodies are pathogenic by directly binding to cell-surface receptors on neuronal cells or that they penetrate cells and inhibit protein synthesis within the cell requires further investigation. Whether T cells are involved in the pathogenesis of CNS disease is an important question that has received little attention. As in the CNS of patients with multiple sclerosis and patients with other autoimmune diseases, excess production of cytokines may contribute significantly to organ inflammation. We report associations between anti-P autoantibodies and certain MHC class II alleles, particularly HLA-DQB1*0602. These findings support a role for T cells in anti-P autoantibody production and encourage further studies of the role of autoantigen-specific T and B cells in injury to the central nervous system.

Lymphoma in patients with rheumatoid arthritis: what is the evidence of a link with methotrexate?

An increasing number of instances of lymphoma in patients with rheumatoid arthritis who are treated with methotrexate continue to appear. The majority of patients with lymphoproliferation have features of immunosuppression-associated lymphoma. Rheumatoid arthritis itself and the actions of methotrexate concur in leading to a immunosuppressed state. Possible oncogenic mechanisms and the risk factors for patients with rheumatoid arthritis to develop lymphoma while receiving methotrexate include: (i) intense immunosuppression and severe disease in combination with genetic predisposition and; (ii) an increased frequency of latent infection with prooncogenic viruses like Epstein-Barr virus. The aetiological role of methotrexate in the development of these lymphomas is supported by the spontaneous remission of these malignancies in some of patients with rheumatoid arthritis after methotrexate has been stopped. The physicians caring for patients with rheumatoid arthritis receiving methotrexate should be vigilant about signs and symptoms suggestive of lymphoma, mostly in those patients with significant comorbidity, long standing and severe disease who are more likely to be immunosuppressed. If a lymphoma appears in these patients, methotrexate should be stopped. Spontaneous remission may occur and a period of observation is advisable when clinically possible. If functional deterioration appears or there are signs of lymphoproliferative organ invasion after several months then specific antineoplastic treatment should be instituted.

Evaluation of radical products from beta-alanine/sugar mixtures by use of GC-MS with the galvinoxyl radical.

We have quantified the radical production of Maillard systems with beta-alanine and different sugars by a method that uses the free radical scavenger capacity of galvinoxyl (2,6-di-tert-butyl-alpha-(3, 5-di-tert-butyl-4-oxo-2,5-cyclohexadiene-1-ylidene)-p-tolyloxy) and a GC-MS separation and quantification. We have compared the results with the spectrophotometrical conclusions and highlight the importance of the radical production in the Maillard systems. The method is precise (CV < 5%), accurate (>97%), sensitive (limit of detection 10 ng/mL galvinoxyl), and may be used for the detection and quantification of radical activity in the chemical and biological systems.

Analysis of the visual evoked potential in anesthesia with sevoflurane and chloral hydrate : (Variability of amplitudes, latencies and morphology of VEP with the depth of anesthesia).

UNLABELLED: The visually evoked potential (VEP) is an electrical signal generated by the occipital cortex in response to light stimulation of the retina. The clinical importance of the VEP consists in the diagnosis of optic nerve diseases and others ocular diseases. For experimental studies of VEP in experimental animals anesthesia is frequently required. Our study sought VEP changes depending on the type and depth of anesthesia. METHODS: this study evaluated VEPs in 20 Wistar rats under two anesthetics. Ten rats were anesthetized with sevoflurane and ten rats with chloral hydrate. RESULTS: The amplitudes, latencies and morphology of the VEP varied with the depth of anesthesia. The latency of VEP increases with the depth of anesthesia and the amplitude of the waves becomes more positive once the anesthesia decreases under sevoflurane and more negative under chloral hydrate. The variability of VEP was different under the two anesthetics with greater peak latencies under sevoflurane than under chloral hydrate at the same depth of anesthesia. IN CONCLUSION: it is important to know the influence of the anesthetic and the depth of anesthesia over VEPS, because they may constitute a confounding factor in studying VEP in different diseases of optic nerve or eyeball.

Electrophysiological changes in optic neuropathy of streptozotocin induced diabetic rats.

UNLABELLED: The visually evoked potentials are electrical signals generated by the occipital cortex due to electrical stimulus. The clinical importance of VEP is to diagnose the functional changes of the optic nerve in different diseases such as diabetic mellitus. Our study sought latency of VEP changes depending on glycemic value and duration of diabetes in Wistar rats. METHODS: this study evaluated the VEP of 25 rats in three groups: control group, diabetic group 1 with glycemic values between 200-400mg/dl and diabetic group 2 with glycemic values between 400 and 600mg/dl. These rats from diabetic group 2 were followed for 4 months and the ones in control group and diabetic group 1 for 5 months. RESULTS: the latency of VEP shows slight changes without any statistical significance in the control group. In diabetic group 1 and 2 similar changes occurred, with statistical significance and the amplitude of the changes was proportional with the glycemic value. The rats had a rapid increase of VEP latency after the induction of diabetes and returned to a normal range in the first month. After a time, when the latencies of VEP were in normal range, a new growth appeared faster and larger as the glycemic values were higher. CONCLUSION: diabetes brings changes to the visual signal transmission and to the central processing, this being revealed by the examination of the visually evoked potential. Increased VEP latency is statistically correlated with the changes that occur at the level of the values of glucose in blood. A rapid growth in blood sugar lowers the visual signal transmission. This change is temporary despite the persistence of elevated blood glucose values, probably by adjusting to the new condition. However, maintaining high glycemic values remotely produces a progressive increase of the delay of the visual signal. This progressive increase is faster as blood glucose levels are higher.

The role of capillary wall in the histogenesis of glomerular diseases.

The glomerular capillary is the most solicited renal component of the local and general systems of integration both under normal and pathological conditions. The alterative and reactive modifications of the glomerular capillary may be the expression of a systematic capillary disease of the initial involvement of ths structure of glomerular corpuscles. The sum of certain kind of lesions of the complex glomerular structure realizes diverse morphofunctional entities of proliferative, membranous, and sclerocicatricial glomerular diseases. The glomerular diseases, irrespective of their nature, induce changes in the balance of the intra-and internephronal relationships, realizing new vicious circles which amplify and maintain the tissular destructions.

Balkan nephritis. A synthetic view on 50 studied cases.

Epidemiological, clinical pathological investigations concerning Balkan nephritis (BN) have revealed some particular aspects which define this condition as a distinct nosologic entity. Its endemic familial character and its occurrence restricted to some limited geographic areas in Bulgaria, Yugoslavia and Romania, are highly unusual. BN leads to chronic impairment of the renal function which is, however, not constantly associated with edema and hypertension. The duration of the disease is prolonged; death takes place from uremia within five to ten years. Gross pathologic changes are consisting of severe bilateral atrophy of the kidneys, with structural changes suggesting a 'renal cirrhosis'. The etiology of the disease is obscure. Investigations carried out by means of electron microscopy and immunofluorescence tests are suggesting that the pathogenesis is rather complex. The role of a persistent tolerated or slow, latent virus infection in certain families, that of some toxic factors, and the implication of autoimmune mechanisms are to be considered.

Tubular structures occurring in cells infected with herpesviruses.

Certain viruses belonging to the Herpesviridae family generate tubular structures of three distinct size ranges late in the growth cycle. The smallest tubules are about 10 to 20 nm in diameter, and are restricted to the cell nucleus, tending to form palisades of lattice-like structures. The medium sized tubular structures are about the width of a core particle, measuring 55 to 65 nm in diameter, while the larger tubular structures are the same diameter as viral capsids, about 80 to 100 nm. Both are rigid capsomered structures, which are sometimes encountered outside the cell nucleus budding onto spherical particles. The available data on some properties of the various tubular structures, as well as speculations concerning their nature and significance are briefly reviewed. Their importance is emphasized for antigen and vaccine production, as well as in differentiating herpesviruses by electron microscopy.

The permeability of aortic endothelium to 125I-BSA in hyperlipidemic hamster. Effect of histamine and serotonin.

The aortic permeability to 125I-bovine serum albumin (BSA) and the effect of histamine and serotonin were investigated in hamsters with diet-induced hyperlipidemia. Animals, fed a cholesterol- and butter-rich diet for five weeks, were sacrificed weekly and the level of serum cholesterol, the aortic permeability, and the morphologic aspect of the vessel wall, were analysed. During this interval, the cholesterolemia increased four-fold, and a progressive lipid accumulation in the intima was recorded. The permeability of the aortic wall was assessed by injecting 125I-BSA into the circulation and detecting the radioactivity in the aortic wall. The effect of the two vasoactive amines was determined by injecting histamine or serotonin concomitantly with the 125I-BSA. The results indicate that during the early stages of experimental hyperlipidemia in hamster, the aortic wall shows an increased permeability to albumin. The process is markedly augmented by histamine and serotonin, predominantly in the abdominal aorta.