Challenges In Care Of Patients Research Articles

Challenges in Long-Term Follow-Up Care of Patients After Kidney Transplantation in Specialized Transplant Centers

Medical care after kidney transplantation requires a close follow-up in specialized transplant centers to minimize complications. Especially in bigger territorial states, the distance the patients have to cover is an underestimated problem for the patients. We performed a survey of 498 patients who underwent kidney transplantation at the transplant center of Hannover Medical School in Lower Saxony in order to find out the burden imposed by having to travel to one of the outpatient clinics affiliated with it for follow-ups. We found that 72% of the patients had to travel more than 100 km to reach the outpatient clinic and the costs for the trip were € 36.30 (standard deviation € 34.15). A distance between home and transplant center of more than 100 km reduced the motivation to attend the outpatient clinic significantly (p=0.023), whereas reimbursement of travel costs improved the motivation to attend the outpatient clinic only partially (p=0.012). We conclude that novel modern media-based care models like televisits could reduce patient burdens and optimize post-transplant care.

An exploration of novice genetic counselors' transitional challenges: Commencement is just the beginning.

Although transitional challenges exist in many professions, no research has explicitly investigated challenges novice genetic counselors encounter as they enter the workforce. This qualitative study explored challenges genetic counselors face when transitioning from student to practicing counselor and their strategies for managing them. Fifteen novice genetic counselors (~1-2years post-degree experience), recruited via the National Society of Genetic Counselors, participated in semi-structured phone interviews. Interview questions explored professional and personal challenges faced in their first 6 months, how challenges changed over time, strategies they used to manage these challenges, and resources they thought would have been helpful to have from the beginning. Inductive analysis of interview data yielded themes including: interpersonal challenges with colleagues (e.g. handling differences of opinion); intrapersonal challenges (e.g. lacking confidence, not feeling ready to 'go solo'); patient care challenges (e.g. being viewed as young/inexperienced); and logistical challenges (e.g. billing). Personal challenges included moving to a new location, preparing for boards, establishing a work-life balance, and factors associated with one's significant others. Strategies to address challenges included seeking support and guidance from experienced genetic counselors and peers, using peer supervision groups, and involvement in community activities. Participants recommended connecting with recent graduates through national and local programs to facilitate the transition from student to genetic counselor. Results suggest the 'transition years' pose a variety of professional and personal challenges. Support and guidance are key to evolving from student to practicing counselor. Creating venues to help novice counselors make connections with colleagues and other recent graduates may be beneficial.

The Impact of Japan Heatwave on Community Emergency Medicine in 2018

Introduction:Due to the heatwave in Japan, the number of patients with heatstroke transported via ambulance hit the highest record according to the Tokyo fire department in 2018. Now, heatwaves are thought to be a natural disaster. Emergency medical professionals located in a Tokyo suburb covering 40,000 individuals experienced a wide range of challenges in patient care with heatstroke.Aim:To assess the impact of the 2018 Japan heatwave on community emergency medical service.Methods:Patients (aged ≥ 16 years) with heatstroke and who were transported to our hospital by ambulance from June to September of 2018 were included. Data were derived from prehospital records and electronic medical records. Weather data was referenced from a Japanese meteorological agency.Results:The number of all-cause cases was 1,764, and the total number of heatstroke cases was 51 (2.9%). Heatstroke cases were concentrated in July and August of 2018. The rate of males was 69%. The average age was 63 ± 23 years. Physical labor was associated with 31% of cases, such as sports in 7.8%. Hospitalization was required in 24%. ICU admission was required in 9.8%. There was no fetal case directly caused by heatstroke in this survey.Discussion:The risk factors of heatstroke considered to be male and elderly. About one-half of heatstroke patients were over 70 years old, and it may have been related to regional characteristics. As mentioned in the Heatstroke STUDY 2012 (Miyake, 2014), most cases which occurred inside residences were found that there was no air conditioner use. There was also an increased number of patients with heatstroke who made emergency visits by themselves. Further investigation is needed annually to estimate the effect of climate change. It is important to make a strong recommendation from public health agency about heatstroke prevention, including air conditioner use during hot weather.

Challenges in the Medical Care of Patients With Autism Spectrum Disorder: The Role of the Consultation-Liaison Psychiatrist

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder that affects one in 40 children. Individuals with ASD have high rates of medical comorbidity, excess mortality, high health care expenditures, and difficulty accessing coordinated medical care. As the prevalence of ASD rises, consultation-liaison (C-L) psychiatrists will be increasingly called upon to assist patients with ASD both in inpatient and outpatient medical settings. In this article, we review the patient, provider, and systems factors that converge to create challenges for delivering high-quality, patient-centered medical care for patients with ASD. Strategies to optimize the care of patients with ASD in medical settings include previsit planning, anticipating and reducing sources of distress, facilitating a patient- and family-centered multidisciplinary approach, employing environmentalinterventions, and using psychopharmacologic treatments.

Prevalence, characteristics, and risk factors of occult uterine cancer in presumed benign hysterectomy

Occult uterine cancer at the time of benign hysterectomy poses unique challenges in patient care. There is large variability and uncertainty in estimated risk of occult uterine cancer in the literature and prior research often did not differentiate/include all subtypes. To thoroughly examine the prevalence of occult uterine cancer in a large population-based sample of women undergoing hysterectomy for presumed benign indications and to identify associated risk factors. Using the New York Statewide Planning and Research Cooperative System database, we identified 229,536 adult women who underwent an inpatient or outpatient hysterectomy for benign indications during the period October 1, 2003 to December 31, 2013 at civilian hospitals and ambulatory surgery centers throughout the state. Diagnosis of corpus uteri cancer within 28 days after the index hysterectomy was determined using linked state cancer registry data. We estimated the prevalence of occult uterine cancer (overall and by subtype) and developed and validated risk prediction models using a random split sample approach. Overall, 0.96% (95% confidence interval: 0.92-1.00%) of the women had occult uterine cancer, including 0.75% (95% confidence interval: 0.71-0.78%) with endometrial carcinoma and 0.22% (95% confidence interval: 0.20-0.23%) with uterine sarcoma. The prevalence of leiomyosarcoma was 0.15% (95% confidence interval: 0.13-0.17%). Seventy-one percent of the endometrial carcinomas and 58.0% of the uterine sarcomas were at localized stage. The risk for occult uterine cancer ranged from 0.10% in women aged 18-29 years to 4.40% in women aged ≥75 years; and varied from 0.14% in women undergoing hysterectomy for endometriosis to 0.62% for uterine fibroids and 8.43% for postmenopausal bleeding. The risk of occult uterine cancer was also significantly associated with race/ethnicity, obesity, comorbidity, and personal history of malignancy. Prediction models incorporating these risk factors had high negative predictive values (99.8% for endometrial carcinoma and 99.9% for uterine sarcoma) and good rule-out accuracy despite low positive predictive value. In women undergoing hysterectomy for presumed benign indications, 0.96% had unexpected uterine cancer. Patient characteristics such as age, surgical indication, and medical history may help guide risk stratification.

Institutionalizing healthcare hackathons to promote diversity in collaboration in medicine

BackgroundMedical students and healthcare professionals can benefit from exposure to cross-disciplinary teamwork and core concepts of medical innovation. Indeed, to address complex challenges in patient care, diversity in collaboration across medicine, engineering, business, and design is critical. However, a limited number of academic institutions have established cross-disciplinary opportunities for students and young professionals within these domains to work collaboratively towards diverse healthcare needs.MethodsDrawing upon best practices from computer science and engineering, healthcare hackathons bring together interdisciplinary teams of students and professionals to collaborate, brainstorm, and build solutions to unmet clinical needs. Over the course of six months, a committee of 20 undergraduates, medical students, and physician advisors organized Stanford University’s first healthcare hackathon (November 2016). Demographic data from initial applications were supplemented with responses from a post-hackathon survey gauging themes of diversity in collaboration, professional development, interest in medical innovation, and educational value. In designing and evaluating the event, the committee focused on measurable outcomes of diversity across participants (skillset, age, gender, academic degree), ideas (clinical needs), and innovations (projects).ResultsDemographic data (n = 587 applicants, n = 257 participants) reveal participants across diverse academic backgrounds, age groups, and domains of expertise were in attendance. From 50 clinical needs presented representing 19 academic fields, 40 teams ultimately formed and submitted projects spanning web (n = 13) and mobile applications (n = 13), artificial intelligence-based tools (n = 6), and medical devices (n = 3), among others. In post-hackathon survey responses (n = 111), medical students and healthcare professionals alike noted a positive impact on their ability to work in multidisciplinary teams, learn from individuals of different backgrounds, and address complex healthcare challenges.ConclusionsHealthcare hackathons can encourage diversity across individuals, ideas, and projects to address clinical challenges. By providing an outline of Stanford’s inaugural event, we hope more universities can adopt the healthcare hackathon model to promote diversity in collaboration in medicine.

Increase in the prevalence of Panton–Valentine leukocidin and clonal shift in community-onset methicillin-resistant Staphylococcus aureus causing skin and soft-tissue infections in the Rhine-Neckar Region, Germany, 2012–2016

Methicillin-resistant Staphylococcus aureus (MRSA) remains a major challenge for patient care. Community-associated (CA)-MRSA often have a fitness and virulence advantage compared with their nosocomial counterparts. Increased mobility, travel activities and migration accelerate the intercontinental spread of virulent CA-MRSA strains. Outpatient clinics are the most important route of entry for CA-MRSA into hospitals. However, systematic data on CA-MRSA in Germany are limited. In this study, community-onset (CO)-MRSA skin and soft-tissue infection (SSTI) isolates in the Rhine-Neckar Region from 2012-2016 were characterised to gain an insight into their molecular epidemiology and to monitor potential introduction of virulent and dominant MRSA strains into our hospital. A total of 2475 patients with S. aureus SSTI were identified in the outpatient departments of our hospital, of which 94 (3.8%) were MRSA. In addition, 40.4% of the CO-MRSA harboured the virulence factor Panton-Valentine leukocidin (PVL). ST8-t008-MRSA-IVa/c (23.7%; 9/39) and ST80-t044-MRSA-IVc (15.8%; 6/38) were the predominant PVL-positive MRSA. Molecular typing and epidemiological data revealed that 42.6% (40/94) of strains could be traced back to a local origin and 44.7% (42/94) were endemic outside of Europe. Resistance to quinolones, clindamycin and macrolides was common, whilst resistance to trimethoprim/sulfamethoxazole, tetracycline, mupirocin, chlorhexidine and fusidic acid was low. No resistance to rifampicin, fosfomycin or linezolid was observed. This study provides insight into the clonal composition of CO-MRSA in the Rhine-Neckar Region. The increase of PVL-positive MRSA and the introduction of imported strains may affect the local MRSA landscape in the near future and should be monitored closely.

Addressing Medical Students' Negative Bias Toward Patients With Obesity Through Ethics Education.

Negative bias toward patients with obesity is an ethical challenge in patient care. Several interventions to mitigate medical students' negative weight bias have been tried but none with an explicit focus on ethics. Here we describe first-year medical students' attitudes toward obesity and our effort to improve their attitudes through an innovative ethics session embedded within the required course, "Obesity, Nutrition, and Behavior Change," at Johns Hopkins University School of Medicine. Precourse survey data were collected from 6 first-year cohorts (2012-2017). Before the ethics session, students take the Implicit Association Test (IAT) to measure implicit weight bias. During the session, students discuss their classmates' personal struggles with weight, beliefs about causes of obesity, and the IAT results. They also watch and discuss video clips from the TV show House depicting negative weight bias. In addition, the 2017 cohort was surveyed 4 months later to evaluate the impact of different components of the session on students' self-reported attitudes. All students responded to the precourse survey. Across cohorts, IAT results revealed that 70% of students held a thin preference, 18% were neutral and 12% held a fat preference. Forty-seven percent had personally struggled with weight loss. While most students thought obesity is a disease (89%) or behavioral (88%), 74% thought it results from ignorance, and 28% thought people with obesity are lazy. Among the 59 respondents to the follow-up survey, 30% reported improvement in their attitudes after the session. Over 40% thought it was useful to discuss students' personal struggles with weight and the IAT and survey results, and over 70% thought the House video clips were useful. Medical students have negative attitudes about obesity that are consistent over time. Providing opportunities for students to discuss their personal experiences and beliefs about obesity within an ethics framework and using popular media as a basis for discussion might improve their attitudes toward obesity.

Viewpoint

hallway care, trafficking, abuse: hallway care, trafficking, abuseOne common adage we learn in medical school is that 80 percent of a diagnosis can be made from a careful medical history and physical exam. The remaining 20 percent, as often taught, is comprised of the myriad laboratory, radiographic, and advanced diagnostic testing available. If this statement is, in fact, true, then the prevalent practice of caring for patients in the hallways of our emergency departments is directly challenging our ability to provide the best care. Hallway care for emergency department patients has been a necessary reality for decades. Recently, rising demands for care from patients with otherwise insufficient health care access coupled with the increasingly common practice of boarding admitted patients in the ED have exacerbated the problem of having too many patients with too few resources for care. Hallway corridors and shared spaces, which used to serve as improvisational care areas reserved for unusually high utilization periods, have now become part of the daily routine in many emergency departments. Our survey study conducted with 409 emergency clinicians showed that 72 percent of respondents reported providing care in ED hallways at least sometimes. (Emerg Med J 2018;35[7]:406; http://bit.ly/2ARAubQ.) Our study further corroborates the common-sense assessment that caring for patients in the hallway is suboptimal and compromises the emergency physician's ability to practice the fundamental diagnostic skills of a detailed medical history and thorough physical exam. Ninety percent of those who practice in the hallway altered their history-taking, while 56 percent altered their physical exam. This then led to delays or failures in diagnoses related with these alterations in the history (35%) and exam (41%). These challenges put the emergency physician right between the rock of providing rising volumes of high-quality care and the hard place of increased limitations to carry out even the most basic practices of emergency medicine. Basic patient care challenges aside, this reality also has implications for other important motivations for emergency physicians. Many of us chose to pursue emergency medicine because of the ability to care for those at the margins of society, the most vulnerable and disenfranchised who have nowhere else to turn for help besides our emergency departments. Attempting to provide care in crowded ED hallways further subjects these vulnerable patients to violations of privacy, loss of dignity, and worse communication. Emergency physicians and staff have often been identified as the front-line defenders against traditionally hidden evils such as human trafficking, domestic violence, and child abuse. Our importance in recent years has also been solidified in challenges involving substance abuse and mental health. Alarmingly, our study identified that each of these issues was negatively affected among those who provide care in the hallway and who reported delays or failures in diagnoses. Approximately 12 percent reported clinical failures related to child abuse, eight percent related to human trafficking, and 37 percent to domestic abuse. Despite these alarming figures, we suspect these are underestimates because of these cases' hidden nature. This will remain a substantial portion of our practice unless some pretty drastic changes are made in our health care delivery model. Legislators, hospital administrators, inpatient care clinicians, and the rest of the care continuum need to recognize the reality that our compromised ability to provide patient care in the appropriate setting will necessarily lead to worse quality of care and outcomes. Inadequate access to care, inpatient boarding in the ED, and prolonged length of stay in the hospital all lead to the downstream effects we have described. We have tolerated this extrinsic factor as status quo in providing care in the emergency department for far too long. It's what we have known since the start of training. But as this practice becomes increasingly prevalent, let's pay attention to the challenges it poses and the mistakes for which we are set up. We ought to recognize that this goes beyond a convenience or comfort factor. Our patients deserve better.

Disturbing and distressing: a mixed methods study on the psychological impact of end of life care on junior doctors.

The Irish Medical Council has identified gaps in knowledge and communications skills of new-entrant doctors in legal, ethical and practical aspects of end of life care. To determine the frequency with which junior doctors deal with end of life care and patient death and to evaluate the impact this has on their psychological wellbeing. A questionnaire was distributed to junior doctors to determine the frequency with which the participants had managed a patient at end of life. An abbreviated Posttraumatic Stress Disorder Checklist-Civilian version was used to evaluate psychological distress. Critical incident technique interviews explored the challenges of caring for patients at end of life. A total of 110 junior doctors in two teaching hospitals in Ireland completed the questionnaire: 39 (35.5%) interns and 71 (64.5%) senior house officers. In addition, 31 interviews were carried out with interns, senior house officers and registrars. The majority (81.8%) had pronounced a death with 39.4% of senior house officers doing so more than 10 times. Three quarters (75.5%) had discussed end of life with a patient's family. Of the 110 respondents that completed the posttraumatic stress disorder checklist, 11.8% screened positively for posttraumatic stress disorder. Challenges identified at interview included lack of knowledge and preparedness, difficulty communicating with family members, a lack of support and a feeling of failure. Junior doctors are regularly carrying out tasks related to end of life care, resulting in high levels of psychological distress. Further training and a change in culture are required.

The nursing challenges of caring for brain-dead patients: A qualitative study

Background: Caring for brain-dead patients is one of the hardest duties for nurses, particularly in Intensive Care Units (ICUs). Objective: This study aimed to explore the nursing challenges of caring for patients diagnosed with brain death. Methods: The present study was conducted as a qualitative conventional content analysis, and data collection was carried out by field notes and 15 semi-structured and in-depth interviews with nurses working in the ICUs. Data analysis co-occurred simultaneously with data collection. Results: Seven themes were extracted from the data: uncertainties and conflicts between physicians and nurses, tensions in breaking the news of patient's brain death to families, stressful experience of caring for the first time, nurses' physical and psychological afflictions due to complex care tensions, stress of being blamed by patients' family, difficulty in tackling the emotions of patients' family, and finally, a sense of lack of support and protection in care. Finally, the main theme of turbulent confrontation with successive chains of tension in caring brain-dead patients was abstracted. Conclusions: Since nurses confront chain of tensions while caring for a brain-dead patient, this can affect the quality of this vital role to keep the transplantable organs viable; furthermore, authorities should implement special support programs for nurses.

Evidence-Based Review and Discussion Points

Evidence-Based Review and Discussion Points

Abstract 2838: Discovery of adaptive resistance pathways and anti-resistance combination therapies in cancer from phosphoproteomic data

Abstract Drug resistance to targeted therapies, either intrinsic (existing before treatment) or acquired (resulting from adaptation to therapy), is a major challenge in patient care. Drug combinations offer a possible solution to prevent drug resistance by blocking multiple routes to tumor proliferation. Discovery of effective combinations remains a challenging task due to complexity of the underlying biological processes and inter-tumor heterogeneity. Here, we developed a statistical pathway analysis method that (i) reveals pathways involved in drug response and adaptive resistance and (ii) nominates combination targets and therapies to down-regulate the resistance pathways. The method is based on the rationale that (i) use of therapies targeting specific genomic aberrations can lead to compensatory responses (e.g. through feedback loop activation in the short term or the development of oncogenic alterations in the long term) leading to drug resistance, and (ii) collective changes in pathway activities are better predictors of resistance and mitigation strategies than individual responses. We construct a pathway model of signaling interactions for measured molecular species through automated extraction of pathway information from Pathway Commons plus manual expert curation. Next, we combine the pathway model with the cell-type-specific drug response data to calculate a TargetScore (TS) for each protein. The score quantifies the adaptive pathway responses to a perturbation by integrating the change in the level of a (phospho)protein along with its pathway neighborhood in response to the single drug. A high TS corresponds to involvement in adaptive response (e.g. upregulation of RTK expression by MEK inhibitor via a feedback loop) and a low TS corresponds to the activity of the drug (e.g. inhibition of ERK phosphorylation by MEK inhibitor). Finally, by identifying the sub-pathways with enriched, high TS values, we determine the adaptive resistance pathways. We test the resulting predictions (combinations of the original single drug with drugs targeting members of the resistance pathways) experimentally. TargetScore is amenable to calculations for hundreds of samples treated with individual (or combinations of) drugs in multiple doses and/or time points and assayed for hundreds to thousands of molecular entities (mRNA or proteomic). Analysis of longitudinal data may allow us to trace the evolution of drug resistance and, potentially, the optimum time points for intervention. The current protocol is defined with a focus on proteomic RPPA data, but can be adapted to other kinds of molecular data associated with adaptive responses. We applied our method to BET-BRD inhibition in ovarian cancer to compare resistance/response pathways in cells with varying degrees sensitivity. The analysis nominated cell-type-specific, anti-resistance combinations involving BET inhibitors. Citation Format: Augustin Luna, Özgün Babur, Gonghong Yan, Emek Demir, Chris Sander, Anil Korkut. Discovery of adaptive resistance pathways and anti-resistance combination therapies in cancer from phosphoproteomic data [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2838.

Nursing care of fragility fracture patients

The challenge of caring for patients with fragility fractures is particularly acute for nursing teams who are in short supply and work with patients following fracture on a 24 h basis, coordinating as well as providing complex care. This paper considers the role of nurses within the orthogeriatric team and highlights the value of effective nursing care in patient outcomes. It explores the nature of nursing for patients with fragility fracture with a focus on the provision of safe and effective care and the coordination of care across the interdisciplinary team. It also highlights the need for specific skills in orthopaedic and geriatric nursing as well as specialist education.

Distinguishing the Clinical Nurse Specialist From Other Graduate Nursing Roles.

Today's healthcare environment poses diverse and complex patient care challenges and requires a highly qualified and experienced nursing workforce. To mitigate these challenges are graduate nursing roles, each with a different set of competencies and expertise. With the availability of many different graduate nursing roles, both patients and healthcare professionals can be confused in understanding the benefit of each role. To gain the maximum benefit from each role, it is important that healthcare providers and administrators are able to distinguish the uniqueness of each role to best use the role and develop strategies for effective collaboration and interprofessional interaction. The purpose of this article was to define the role, educational preparation, role differences, and practice competencies for the clinical nurse specialist (CNS), nurse practitioner, clinical nurse leader, and nurse educator/staff development educator roles. A second purpose was to provide role clarity and demonstrate the unique value the CNS brings to the healthcare environment. Using evidence and reviewing role competencies established by varying organizations, each role is presented with similarities and differences among the roles discussed. In addition, collaboration among the identified roles was reviewed, and recommendations were provided for the new and practicing CNSs. Although there are some similarities among the graduate nursing roles such as in educational, licensing, and certification requirements, each role must be understood to gain the full role scope and benefit and glean the anticipated outcomes. Healthcare providers must be aware of the differences in graduate nursing roles, especially in comparing the CNS with other roles to avoid confusion that may lead to roles being underused with a limited job scope. The CNS provides a unique set of services at all system outcome levels and is an essential part of the healthcare team especially in the acute care setting.

Mediating Systems of Care: Emergency Calls to Long-Term Care Facilities at Life's End.

Nursing home (NH) residents account for over 2.2 million emergency department visits yearly; the majority are cared for and transported by prehospital providers (emergency medical technicians and paramedics). The purpose of this study was to investigate prehospital providers' perceptions of emergency calls at life's end. This article focuses on perceptions of end-of-life calls in long-term care (LTC). This pilot study employed a descriptive cross-sectional design. Concepts from the symbolic interaction theory guided the exploration of perceptions and interpretations of emergency calls in LTC facilities. A purposeful sample of prehospital providers was developed from one agency in a small northeastern U.S. city. Semistructured interviews were conducted with 43 prehospital providers to explore their perceptions of factors that trigger emergency end-of-life calls in LTC facilities. Qualitative data analysis involved iterative coding in an inductive process that included open, systematic, focused, and axial coding. Interview themes illustrated the contributing factors as follows: care crises; dying-related turmoil; staffing ratios; and organizational protocols. Distress was crosscutting and present in all four themes. The findings illuminate how prehospital providers become mediators between NHs and emergency departments by managing tension, conflict, and challenges in patient care between these systems and suggest the importance of further exploration of interactions between LTC staff, prehospital providers, and emergency departments. Enhanced communication between LTC facilities and prehospital providers is important to address potentially inappropriate calls and transport requests and to identify means for collaboration in the care of sick frail residents.

The nurse's challenge of caring for patients with chronic obstructive pulmonary disease in primary health care.

AimThe aim was to describe asthma and chronic obstructive pulmonary disease nurses′ experiences of caring for patients with chronic obstructive pulmonary disease in primary health care.DesignDescriptive qualitative research.MethodsTen asthma and chronic obstructive pulmonary disease specialized nurses were interviewed. Systematic Text Condensation by Malterud was used to analyse the data.ResultsTwo main categories were found: the patient‐nurse relationship and available resources. Several challenges emerged when connecting with patients and the nurses found it difficult to individualize care. They struggled with a lack of time and support from other professionals. Being responsible for asthma and chronic obstructive pulmonary disease practice was experienced as positive, but could become overwhelming. The asthma and chronic obstructive pulmonary disease nurses described several challenges and the need for support and resources to provide the best possible care for patients with chronic obstructive pulmonary disease.

Chemokine Signaling Facilitates Early-Stage Breast Cancer Survival and Invasion through Fibroblast-Dependent Mechanisms.

Ductal carcinoma in situ (DCIS) is the most common form of breast cancer, with 50,000 cases diagnosed every year in the United States. Overtreatment and undertreatment remain significant clinical challenges in patient care. Identifying key mechanisms associated with DCIS progression could uncover new biomarkers to better predict patient prognosis and improve guided treatment. Chemokines are small soluble molecules that regulate cellular homing through molecular gradients. CCL2-mediated recruitment of CCR2+ macrophages are a well-established mechanism for metastatic progression. Although the CCL2/CCR2 pathway is a therapeutic target of interest, little is known about the role of CCR2 expression in breast cancer. Here, using a mammary intraductal injection (MIND) model to mimic DCIS formation, the role of CCR2 was explored in minimally invasive SUM225 and highly invasive DCIS.com breast cancer cells. CCR2 overexpression increased SUM225 breast cancer survival and invasion associated with accumulation of CCL2 expressing fibroblasts. CCR2-deficient DCIS.com breast cancer cells formed fewer invasive lesions with fewer CCL2+ fibroblasts. Cografting CCL2-deficient fibroblasts with DCIS.com breast cancer cells in the subrenal capsule model inhibited tumor invasion and survival associated with decreased expression of aldehyde dehydrogenase (ALDH1), a proinvasive factor, and decreased expression of HTRA2, a proapoptotic serine protease. Through data mining analysis, high expression of CCR2 and ALDH1 and low HTRA2 expression were correlated with poor prognosis of breast cancer patients.Implications: This study demonstrates that CCR2 overexpression in breast cancer drives early-stage breast cancer progression through stromal-dependent expression of CCL2 with important insight into prognosis and treatment of DCIS. Mol Cancer Res; 16(2); 296-308. ©2017 AACR.

ARDS: challenges in patient care and frontiers in research.

This review discusses the clinical challenges associated with ventilatory support and pharmacological interventions in patients with acute respiratory distress syndrome (ARDS). In addition, it discusses current scientific challenges facing researchers when planning and performing trials of ventilatory support or pharmacological interventions in these patients.Noninvasive mechanical ventilation is used in some patients with ARDS. When intubated and mechanically ventilated, ARDS patients should be ventilated with low tidal volumes. A plateau pressure <30 cmH2O is recommended in all patients. It is suggested that a plateau pressure <15 cmH2O should be considered safe. Patient with moderate and severe ARDS should receive higher levels of positive end-expiratory pressure (PEEP). Rescue therapies include prone position and neuromuscular blocking agents. Extracorporeal support for decapneisation and oxygenation should only be considered when lung-protective ventilation is no longer possible, or in cases of refractory hypoxaemia, respectively. Tracheotomy is only recommended when prolonged mechanical ventilation is expected.Of all tested pharmacological interventions for ARDS, only treatment with steroids is considered to have benefit.Proper identification of phenotypes, known to respond differently to specific interventions, is increasingly considered important for clinical trials of interventions for ARDS. Such phenotypes could be defined based on clinical parameters, such as the arterial oxygen tension/inspiratory oxygen fraction ratio, but biological marker profiles could be more promising.

The challenge of caring for patients with rare diseases

The challenge of caring for patients with rare diseases