Factors associated with nurses' perceptions about quality of end-of-life care

AIM

To examine the factors associated with nurses' perceptions of the quality of end-of-life care.

BACKGROUND

With increasing demand for hospitals to provide end-of-life care, the low quality of palliative care provided in hospital settings is an issue of growing concern in developing countries. Most dying patients receive their care from general nurses, irrespective of the nurses' specialty or level of training.

METHOD

A structured cross-sectional questionnaire survey was conducted of 553 nurses working at a teaching hospital in Malaysia.

RESULTS

The mean scores for nurses' knowledge about end-of-life care, their attitudes towards end-of-life care and the perceived quality of end-of-life care were low. The factors identified as significantly associated with the quality of end-of-life care were nurses' levels of knowledge and their attitudes towards end-of-life care.

DISCUSSION

Factors that contributed to the low quality of end-of-life care were inadequate knowledge and negative attitudes. These findings may reflect that end-of-life care education is not well integrated into nursing education.

CONCLUSION

The findings of this study suggest that there is a need to increase the nurses' level of knowledge and improve their attitude towards end-of-life care in order to enhance the quality of care provided to dying patients.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Nurse managers and hospital policymakers should develop strategies to enhance nurses' level of knowledge, as well as providing adequate emotional support for nurses who care for dying patients and their families. Nurses should be proactive in increasing their knowledge and adopting more positive attitudes towards end-of-life care.

Combining Medical Informatics and Bioinformatics toward Tools for Personalized Medicine

Objectives: Key bioinformatics and medical informatics research areas need to be identified to advance knowledge and understanding of disease risk factors and molecular disease pathology in the 21st century toward new diagnoses, prognoses, and treatments. Methods: Three high-impact informatics areas are identified: predictive medicine (to identify significant correlations within clinical data using statistical and artificial intelligence methods), along with pathway informatics and cellular simulations (that combine biological knowledge with advanced informatics to elucidate molecular disease pathology).

Results: Initial predictive models have been developed for a pilot study in Huntington’s disease. An initial bioinformatics platform has been developed for the reconstruction and analysis of pathways, and work has begun on pathway simulation.

Conclusions: A bioinformatics research program has been established at GE Global Research Center as an important technology toward next generation medical diagnostics. We anticipate that 21st century medical research will be a combination of informatics tools with traditional biology wet lab research, and that this will translate to increased use of informatics techniques in the clinic.

Imaging spectroscopy of solar radio burst fine structures

Solar radio observations provide a unique diagnostic of the outer solar atmosphere. However, the inhomogeneous turbulent corona strongly affects the propagation of the emitted radio waves, so decoupling the intrinsic properties of the emitting source from the effects of radio wave propagation has long been a major challenge in solar physics. Here we report quantitative spatial and frequency characterization of solar radio burst fine structures observed with the Low Frequency Array, an instrument with high-time resolution that also permits imaging at scales much shorter than those corresponding to radio wave propagation in the corona. The observations demonstrate that radio wave propagation effects, and not the properties of the intrinsic emission source, dominate the observed spatial characteristics of radio burst images. These results permit more accurate estimates of source brightness temperatures, and open opportunities for quantitative study of the mechanisms that create the turbulent coronal medium through which the emitted radiation propagates.

Radio observations of the solar atmosphere provide a unique view on the non-thermal processes in the outer atmosphere. Here the authors use LOFAR observations to demonstrate that the observed radio burst characteristics are dominated by propagation effects rather than underlying emission variations.

Comparison of two neurotrophic serpins reveals a small fragment with cell survival activity

PURPOSE

Protease nexin-1 (PN-1), a serpin encoded by the SERPINE2 gene, has serine protease inhibitory activity and neurotrophic properties in the brain. PN-1 inhibits retinal angiogenesis; however, PN-1's neurotrophic capacities in the retina have not yet been evaluated. Pigment epithelium-derived factor (PEDF) is a serpin that exhibits neurotrophic and antiangiogenic activities but lacks protease inhibitory properties. The aim of this study is to compare PN-1 and PEDF.

METHODS

Sequence comparisons were performed using computer bioinformatics programs. Mouse and bovine eyes, human retina tissue, and ARPE-19 cells were used to prepare RNA and protein samples. Interphotoreceptor matrix lavage was obtained from bovine eyes. Gene expression and protein levels were evaluated with reverse-transcription PCR (RT-PCR) and western blotting, respectively. Recombinant human PN-1, a version of PN-1 referred to as PN-1[R346A] lacking serine protease inhibitory activity, and PEDF proteins were used, as well as synthetic peptides designed from PEDF and PN-1 sequences. Survival activity in serum-starved, rat-derived retinal precursor (R28) cells was assessed with terminal deoxynucleotidyl transferase (TdT) dUTP nick-end labeling (TUNEL) cell death assays. Bcl2 levels were measured with RT-PCR.

RESULTS

PN-1 is analogous in primary and tertiary structure to PEDF. A region in PN-1 shares homology with the neurotrophic active region of PEDF, a 17-residue region within alpha helix C. The native human retina, ARPE-19 cells, and murine RPE and retina expressed the gene for PN-1 (SERPINE2 and Serpine2 mRNA). The retina, ARPE-19 cell lysates, and bovine interphotoreceptor matrix contained PN-1 protein. The addition of PN-1, PN-1[R346A], or the 17mer peptide of PN-1 to serum-starved retina cells decreased the number of TUNEL-positive nuclei relative to the untreated cells, such as PEDF. PN-1, PN-1[R346A], and PN-1-17mer treatments increased the Bcl2 transcript levels in serum-starved cells, as seen with PEDF.

CONCLUSIONS

PN-1 and PEDF share structural and functional features, and expression patterns in the retina. These serpins' mechanisms of action as cell survival factors are independent of serine protease inhibition. We have identified PN-1 as a novel factor for the retina that may play a neuroprotective role in vivo, and small peptides as relevant candidates for preventing retinal degeneration.

A Novel Inhibitor of 5-Lipoxygenase (5-LOX) Prevents Oxidative Stress-Induced Cell Death of Retinal Pigment Epithelium (RPE) Cells

PURPOSE

5-Lipoxygenase (5-LOX) oxygenates arachidonic acid to form 5-hydroperoxyeicosatetraenoic acid, which is further converted into biologically detrimental leukotrienes, such as leukotriene B4 (LTB4). The RPE and retina express the PNPLA2 gene for pigment epithelium-derived factor receptor (PEDF-R), a lipase involved in cell survival. The purpose here was to investigate the role of PEDF-R on the 5-LOX pathway in oxidative stress of RPE.

METHODS

Lipoxygenase activity assays were performed with soybean and potato lipoxygenase. Binding was evaluated by peptide-affinity chromatography and pull-down assays with PEDF-R-derived synthetic peptides or recombinant protein. Oxidative stress was induced in human ARPE-19 and primary pig RPE cells with indicated concentrations of H2O2/TNF-α. Reverse transcription-PCR of ALOX5 and PNPLA2 genes was performed. Cell viability and death rates were determined using respective biomarkers. Leukotriene B4 levels were measured by ELISA.

RESULTS

Among five peptides spanning between positions Leu159 and Met325 of human PEDF-R polypeptide, only two overlapping peptides, E5b and P1, bound and inhibited lipoxygenase activity. Human recombinant 5-LOX bound specifically to peptide P1 and to His6/Xpress-tagged PEDF-R via ionic interactions. The two inhibitor peptides E5b and P1 promoted cell viability and decreased cell death of RPE cells undergoing oxidative stress. Oxidative stress decreased the levels of PNPLA2 transcripts with no effect on ALOX5 expression. Exogenous additions of P1 peptide or overexpression of the PNPLA2 gene decreased both LTB4 levels and death of RPE cells undergoing oxidative stress.

CONCLUSIONS

A novel peptide region of PEDF-R inhibits 5-LOX, which intersects with RPE cell death pathways induced by oxidative stress.

SYN-004 (ribaxamase), an oral beta-lactamase, mitigates antibiotic-mediated dysbiosis in a porcine gut microbiome model

AIM

To evaluate an antibiotic inactivation strategy to protect the gut microbiome from antibiotic-mediated damage.

METHODS AND RESULTS

SYN-004 (ribaxamase) is an orally delivered beta-lactamase intended to degrade penicillins and cephalosporins within the gastrointestinal tract to protect the microbiome. Pigs (20 kg, n = 10) were treated with ceftriaxone (CRO) (IV, 50 mg kg^-1 , SID) for 7 days and a cohort (n = 5) received ribaxamase (PO, 75 mg, QID) for 9 days beginning the day before antibiotic administration. Ceftriaxone serum levels were not statistically different in the antibiotic-alone and antibiotic + ribaxamase groups, indicating ribaxamase did not alter systemic antibiotic levels. Whole-genome metagenomic analyses of pig faecal DNA revealed that CRO caused significant changes to the gut microbiome and an increased frequency of antibiotic resistance genes. With ribaxamase, the gut microbiomes were not significantly different from pretreatment and antibiotic resistance gene frequency was not increased.

CONCLUSION

Ribaxamase mitigated CRO-mediated gut microbiome dysbiosis and attenuated propagation of the antibiotic resistance genes in pigs.

SIGNIFICANCE AND IMPACT OF THE STUDY

Damage of the microbiome can lead to overgrowth of pathogenic organisms and antibiotic exposure can promote selection for antibiotic-resistant micro-organisms. Ribaxamase has the potential to become the first therapy designed to protect the gut microbiome from antibiotic-mediated dysbiosis and reduce emergence of antibiotic resistance.

Minimally invasive periacetabular osteotomy using a modified Smith-Petersen approach: technique and early outcomes

AIMS

Periacetabular osteotomy is an effective way of treating symptomatic hip dysplasia. We describe a new minimally invasive technique using a modification of the Smith-Peterson approach. We performed a prospective, longitudinal cohort study to assess for any compromise in acetabular correction when using this approach, and to see if the procedure would have a higher complication rate than that quoted in the literature for other approaches. We also assessed for any improvement in functional outcome.

PATIENTS AND METHODS

From 168 consecutive patients (189 hips) who underwent acetabular correction between March 2010 and March 2013 we excluded those who had undergone previous pelvic surgery for DDH and those being treated for acetabular retroversion. The remaining 151 patients (15 men, 136 women) (166 hips) had a mean age of 32 years (15 to 56) and the mean duration of follow-up was 2.8 years (1.2 to 4.5). In all 90% of cases were Tönnis grade 0 or 1. Functional outcomes were assessed using the Non Arthritic Hip Score (NAHS), University of California, Los Angeles (UCLA) and Tegner activity scores.

RESULTS

The mean pre-operative lateral centre-edge angle was 14.2° (-5° to 30°) and the mean acetabular index was 18.4° (4° to 40°). Post-operatively these were 31° (18° to 46°) and 3° (-7° to 29°), respectively, a significant improvement in both (p < 0.001). Allogenic blood transfusion was required in two patients (1.2%). There were no major nerve or vascular complications, and no wound infections. At the time of last follow-up, we noted a significant improvement in functional outcome scores: UCLA improved by 2.31 points, Tegner improved by 1.08 points, and the NAHS improved by 25.4 points (p < 0.001 for each). Hypermobility and longer duration of surgery were significant negative predictors for a good post-operative UCLA score, while residual retroversion was a positive predictor of post-operative UCLA score.

CONCLUSION

We have found this approach to be safe and effective, facilitating early recovery from surgery. Cite this article: Bone Joint J 2017;99-B:22-8.

Perceptions of Healthcare Professionals on the Usage of Percutaneous Endoscopic Gastrostomy in a Teaching Hospital from a Middle-Income South East Asian Country

OBJECTIVE

To explore the perceptions of healthcare professionals' (HCPs) in a South East Asian nation towards percutaneous endoscopic gastrostomy (PEG) feeding.

DESIGN

Semi-structured, qualitative interviews.

SETTINGS

A teaching hospital in Kuala Lumpur, Malaysia.

PARTICIPANTS

A total of 17 healthcare professionals aged 23-43 years, 82% women.

RESULTS

Thematic analysis revealed five themes that represent HCPs' perceptions in relation to the usage of PEG feeding: 1) knowledge of HCPs, 2) communication, 3) understanding among patients, and 4) financial and affordability.

CONCLUSION

The rationale for reluctance towards PEG feeding observed in this regions was explained by lack of education, knowledge, communication, team work, and financial support. Future studies should assess the effects of educational programmes among HCPs and changes in policies to promote affordability on the utilization of PEG feeding in this region.

Transient Weakening of Earth's Magnetic Shield Probed by a Cosmic Ray Burst

The GRAPES-3 tracking muon telescope in Ooty, India measures muon intensity at high cutoff rigidities (15-24 GV) along nine independent directions covering 2.3 sr. The arrival of a coronal mass ejection on 22 June 2015 18:40 UT had triggered a severe G4-class geomagnetic storm (storm). Starting 19:00 UT, the GRAPES-3 muon telescope recorded a 2 h high-energy (∼20  GeV) burst of galactic cosmic rays (GCRs) that was strongly correlated with a 40 nT surge in the interplanetary magnetic field (IMF). Simulations have shown that a large (17×) compression of the IMF to 680 nT, followed by reconnection with the geomagnetic field (GMF) leading to lower cutoff rigidities could generate this burst. Here, 680 nT represents a short-term change in GMF around Earth, averaged over 7 times its volume. The GCRs, due to lowering of cutoff rigidities, were deflected from Earth's day side by ∼210° in longitude, offering a natural explanation of its night-time detection by the GRAPES-3. The simultaneous occurrence of the burst in all nine directions suggests its origin close to Earth. It also indicates a transient weakening of Earth's magnetic shield, and may hold clues for a better understanding of future superstorms that could cripple modern technological infrastructure on Earth, and endanger the lives of the astronauts in space.

Ventilator Associated Pneumonia in an Infant Caused by Stenotrophomonas maltophila - A Case Report

Stenotrophomonas maltophila (S.maltophila) is an aerobic Gram-negative bacillus that is a frequent colonizer of fluids used in the hospital setting. The organism is known to cause life threatening infections in immuno-compromised patients especially in those who are neutropenic, on chemotherapy or on broad spectrum antibiotics. We report a case of ventilator associated pneumonia caused by Stenotrophomonas maltophila in a two-month old infant who later developed multi organ dysfunction syndrome. In seriously ill paediatric patients, S.maltophila should also be considered as a possible pathogen for Ventilator-Associated Pneumonia (VAP), hence empiric antibiotic choice should include antimicrobials that are active against S. maltophila. An early identification and treatment of VAP with Multi-Drug Resistant (MDR) strains with appropriate antibiotics has a significant impact on morbidity and mortality.

Three-Dimensional Icosahedral Phase Field Quasicrystal

We investigate the formation and stability of icosahedral quasicrystalline structures using a dynamic phase field crystal model. Nonlinear interactions between density waves at two length scales stabilize three-dimensional quasicrystals. We determine the phase diagram and parameter values required for the quasicrystal to be the global minimum free energy state. We demonstrate that traits that promote the formation of two-dimensional quasicrystals are extant in three dimensions, and highlight the characteristics required for three-dimensional soft matter quasicrystal formation.

Small Retinoprotective Peptides Reveal a Receptor-binding Region on Pigment Epithelium-derived Factor

The cytoprotective effects of pigment epithelium-derived factor (PEDF) require interactions between an as of a yet undefined region with a distinct ectodomain on the PEDF receptor (PEDF-R). Here we characterized the area in PEDF that interacts with PEDF-R to promote photoreceptor survival. Molecular docking studies suggested that the ligand binding site of PEDF-R interacts with the neurotrophic region of PEDF (44-mer, positions 78-121). Binding assays demonstrated that PEDF-R bound the 44-mer peptide. Moreover, peptide P1 from the PEDF-R ectodomain had affinity for the 44-mer and a shorter fragment within it, 17-mer (positions 98-114). Single residue substitutions to alanine along the 17-mer sequence were designed and tested for binding and biological activity. Altered 17-mer[R99A] did not bind to the P1 peptide, whereas 17-mer[H105A] had higher affinity than the unmodified 17-mer. Peptides 17-mer, 17-mer[H105A], and 44-mer exhibited cytoprotective effects in cultured retina R28 cells. Intravitreal injections of these peptides and PEDF in the rd1 mouse model of retinal degeneration decreased the numbers of dying photoreceptors, 17-mer[H105A] being most effective. The blocking peptide P1 hindered their protective effects both in retina cells and in vivo. Thus, in addition to demonstrating that the region composed of positions 98-114 of PEDF contains critical residues for PEDF-R interaction that mediates survival effects, the findings reveal distinct small PEDF fragments with neurotrophic effects on photoreceptors.