Outcomes sensitive to critical care nurse staffing levels: A systematic review.

OBJECTIVE: To determine associations between variations in registered nurse staffing levels in adult critical care units and outcomes such as patient, nurse, organisational and family outcomes. METHODS: We published and adhered to a protocol, stored in an open access repository and searched for quantitative studies written in the English language and held in CINAHL Plus, MEDLINE, PsycINFO, SCOPUS and NDLTD databases up to July 2020. Three authors independently extracted data and critically appraised papers meeting the inclusion criteria. Results are summarised in tables and discussed in terms of strength of internal validity. A detailed review of the two most commonly measured outcomes, patient mortality and nosocomial infection, is also presented. RESULTS: Our search returned 7960 titles after duplicates were removed; 55 studies met the inclusion criteria. Studies with strong internal validity report significant associations between lower levels of critical care nurse staffing and increased odds of both patient mortality (1.24-3.50 times greater) and nosocomial infection (3.28-3.60 times greater), increased hospital costs, lower nurse-perceived quality of care and lower family satisfaction. Meta-analysis was not feasible because of the wide variation in how both staffing and outcomes were measured. CONCLUSIONS: A large number of studies including several with high internal validity provide evidence that higher levels of critical care nurse staffing are beneficial to patients, staff and health services. However, inconsistent approaches to measurement and aggregation of staffing levels reported makes it hard to translate findings into recommendation for safe staffing in critical care.

Fra-1 controls motility of bladder cancer cells via transcriptional upregulation of the receptor tyrosine kinase AXL.

Fos-related antigen 1 (Fra-1) is a Fos family member overexpressed in several types of human cancers. Here, we report that Fra-1 is highly expressed in the muscle-invasive form of the carcinoma of the bladder (80%) and to a lesser extent in superficial bladder cancer (42%). We demonstrate that in this type of cancer Fra-1 is regulated via a C-terminal instability signal and C-terminal phosphorylation. We show that manipulation of Fra-1 expression levels in bladder cancer cell lines affects cell morphology, motility and proliferation. The gene coding for AXL tyrosine kinase is directly upregulated by Fra-1 in bladder cancer and in other cell lines. Importantly, our data demonstrate that AXL mediates the effect of Fra-1 on tumour cell motility but not on cell proliferation. We suggest that AXL may represent an attractive therapeutic target in cancers expressing high Fra-1 levels.

Evaluation of the cancer chemopreventive efficacy of rice bran in genetic mouse models of breast, prostate and intestinal carcinogenesis.

Brown rice is a staple dietary constituent in Asia, whereas rice consumed in the Western world is generally white, obtained from brown rice by removal of the bran. We tested the hypothesis that rice bran interferes with development of tumours in TAg, TRansgenic Adenocarcinoma of the Mouse Prostate (TRAMP) or Apc(Min) mice, genetic models of mammary, prostate and intestinal carcinogenesis, respectively. Mice received rice bran (30%) in AIN-93G diet throughout their post-weaning lifespan. In TAg and TRAMP mice, rice bran did not affect carcinoma development. In TRAMP or wild-type C57Bl6/J mice, dietary rice bran increased kidney weight by 18 and 20%, respectively. Consumption of rice bran reduced numbers of intestinal adenomas in Apc(Min) mice by 51% (P<0.01), compared to mice on control diet. In parallel, dietary rice bran decreased intestinal haemorrhage in these mice, as reflected by increased haematocrit. At 10% in the diet, rice bran did not significantly retard Apc(Min) adenoma development. Likewise, low-fibre rice bran (30% in the diet) did not affect intestinal carcinogenesis, suggesting that the fibrous constituents of the bran mediate chemopreventive efficacy. The results suggest that rice bran might be beneficially evaluated as a putative chemopreventive intervention in humans with intestinal polyps.

Growth-inhibitory and cell cycle-arresting properties of the rice bran constituent tricin in human-derived breast cancer cells in vitro and in nude mice in vivo.

Tricin, a flavone found in rice bran, inhibits the growth of human-derived malignant MDA-MB-468 breast tumour cells at submicromolar concentrations. As part of the exploration of tricin as a potential cancer chemopreventive agent, we investigated the duration and cell cycle specificity of growth inhibition elicited by tricin in vitro and the effect of tricin on the development of MDA-MB-468 tumours grown in immune-compromised MF-1 mice in vivo. Preincubation of MDA-MB-468 cells with tricin (1-40 microM) for 72 h compromised cell growth after tricin removal, and such irreversibility was not observed in human breast-derived nonmalignant HBL-100 cells. Tricin (>/=5 microM) arrested MDA-MB-468 cells in the G2/M phase of the cell cycle without inducing apoptosis as adjudged by annexin V staining. In nude mice consumption of tricin with the diet (0.2%, w w(-1)) from 1 week prior to MDA-MB-468 cell implantation failed to impede tumour development. Steady-state levels of tricin in plasma, breast tumour tissue and intestinal mucosa, as measured by HPLC, were 0.13 microM and 0.11 and 63 nmol g(-1), respectively. Cells were exposed to tricin (0.11, 1.1 or 11 microM) in vitro for 72 h and then implanted into mice. The volume of tumours in animals bearing cells pre-exposed to 11 microM tricin was less than a third of that in mice with control cells, while tumours from cells incubated with 0.1 or 1.1 microM tricin were indistinguishable from controls. These results suggest that the potent breast tumour cell growth-inhibitory activity of tricin in vitro does not directly translate into activity in the nude mouse bearing the MDA MB-468 tumour. While the results do not support the notion that tricin is a promising candidate for breast cancer chemoprevention, its high levels in the gastrointestinal tract after dietary intake render exploration of its ability to prevent colorectal carcinogenesis propitious.

Comparison of the effect of oestradiol, tamoxifen and raloxifene on nerve growth factor-alpha expression in specific neonatal mouse uterine cell types using laser capture microdissection.

Oral dosing of CD-1 mice on days 2-5 after birth with tamoxifen but not raloxifene disrupts the development of the myometrium, resulting in adult uterine adenomyosis. Using laser capture microdissection and RT-PCR we have investigated nerve growth factor (NGF) and cognate receptor expression in uterine cells of 6-day-old pups that may be important in early developmental changes that give rise to adenomyosis. NGF down-regulation is known to occur during terminal myogenic differentiation. NGF was found exclusively in endometrial luminal epithelium of controls. It was up-regulated 18-fold in the luminal epithelium following dosing with tamoxifen but not raloxifene. Western blotting for NGF protein in the whole uterus showed a 25-fold increase after tamoxifen treatment. Expression of the low affinity p75 neutrophin receptor (p75(NTR)) was twofold higher in the myometrium compared with luminal epithelium or stroma. This was not altered following tamoxifen treatment. There was no detectable expression of high affinity tyrosine kinase receptor (trkA(NGFR)). This study shows luminal epithelial cells of the endometrium primarily form NGF. This suggests that NGF normally regulates the differentiation of the mesenchyme into uterine myocytes through paracrine mechanisms and that an early disturbance of this process plays a key role in the subsequent development of adenomyosis.

Adenomyosis--a result of disordered stromal differentiation.

Adenomyosis is a fairly frequent disorder in adult women characterized by the haphazard location of endometrial glands and stroma deep within the myometrium of the uterus. This study compared the effects on uterine development of the selective estrogen receptor modulators, tamoxifen, toremifene, and raloxifene with estradiol when given orally to female mice on days 2 to 5 after birth. Uterine adenomyosis was found in all (14 of 14) mice dosed with tamoxifen and most mice (12 of 14) treated with toremifene, but in none of the vehicle-dosed controls, in only one animal treated with raloxifene at 42 and 90 days after dosing and in none of the mice treated with estradiol at 42 days. At 6 days, the uterus in the groups that developed a high incidence of adenomyosis showed histological evidence of disturbed differentiation of the myometrium. Gene-expression XY-scatterplots using Clontech mouse 1.2 Atlas mouse cDNA expression arrays analyzing total uterine RNA showed nerve growth factor-alpha, preadipocyte factor-1, and insulin-like growth factor-2 were key genes differentially modified by tamoxifen or toremifene treatment, relative to the controls. As these genes may play an important role in regulating differentiation and development of the myometrium, these data suggest that adenomyosis may be caused primarily by defects in the formation of the myometrium.

Comparisons of the effects of tamoxifen, toremifene and raloxifene on enzyme induction and gene expression in the ovariectomised rat uterus.

This study compares the actions of oestradiol, tamoxifen, toremifene and raloxifene on enzyme and gene expression in uterine tissues of ovariectomised rats over 72 h. The time-course for the induction of ornithine decarboxylase by the compounds showed a rapid biphasic response, while for creatine kinase brain type (BB) there was a continued increase over 72 h. The efficacy of induction showed that, with both markers, oestradiol gave the highest induction level, followed by tamoxifen or toremifene and then raloxifene. RT-PCR demonstrated that all compounds decreased oestrogen receptor (ER) alpha, ERbeta and ERbeta2 gene expression, 8-24 h after the first dose, suggesting that down-regulation of ER is not the primary cause of the difference in efficacy between these compounds. Using cDNA arrays, expression of 512 genes was examined in the uteri of oestradiol- or tamoxifen-treated rats. Both compounds resulted in the up-regulation of heat-shock protein 27, telomerase-associated protein 1 and secretin. However, most surprising was the marked down-regulation of Wilms' tumour and retinoblastoma genes. We speculate that this may result in a loss of regulation of the transition from the G1 to the S phase in the cell cycle and may make cells more vulnerable to the carcinogenic effects of tamoxifen in this tissue.

"Have you seen this?" Diffuse hepatic apoptosis.

One important cell death pathway involves binding of the cell surface receptor Fas, which recruits and activates specific initiator and effector caspases. In this study Balb/c mice were injected with monoclonal antibody to Fas either alone or followed by the tripeptide caspase inhibitor Z-VAD.fmk. At four hours mice were killed along with concurrent controls and tissues processed for histological examination and immunocytochemical staining for cleaved caspase-3. The livers in all animals treated with Fas alone showed massive apoptosis and positive staining for cleaved caspase-3 whereas those treated with Fas and Z-VAD.fmk or controls showed little or no apoptosis or staining for cleaved caspase-3. These features suggest that massive apoptosis may be important in fulminant liver disease.

Toxicologic lesions associated with two related inhibitors of oxidosqualene cyclase in the dog and mouse.

Two novel hypolipidaemic agents, both members of the aminopyrimidine series, with a mode of action of inhibition of oxidosqualene cyclase (OSC), were administered orally to dogs and mice for 14 and 28 days. Both compounds produced a similar spectrum of pathologic changes. In dogs, the agents produced equatorial single cell necrosis and cataract in the lens (also observed clinically); atrophy, ulceration, and inflammation of the cornea; hyperkeratosis, acanthosis, hair papillary atrophy, and inflammation of the skin; and epithelial degeneration and sperm granuloma in the epididymides. One female dog showed signs of liver toxicity. In mice, severe cataract formation was seen with both compounds, and liver toxicity was produced by one of the compounds. The severity and speed of onset of the cataract formation were very marked. The changes seen were dissimilar to those reported with the most commonly used class of hypolipidaemic agents in the clinic, the hydroxymethyl glutaryl coenzyme A (HMGCoA) reductase inhibitors but were reminiscent of those reported for the hypolipidaemic agent Triparanol. which was predictive of toxicity seen in man.

Applications of gene replacement technology to Streptomyces clavuligerus strain development for clavulanic acid production.

Cephamycin C production was blocked in wild-type cultures of the clavulanic acid-producing organism Streptomyces clavuligerus by targeted disruption of the gene (lat) encoding lysine epsilon-aminotransferase. Specific production of clavulanic acid increased in the lat mutants derived from the wild-type strain by 2- to 2.5-fold. Similar beneficial effects on clavulanic acid production were noted in previous studies when gene disruption was used to block the production of the non-clavulanic acid clavams produced by S. clavuligerus. Therefore, mutations in lat and in cvm1, a gene involved in clavam production, were introduced into a high-titer industrial strain of S. clavuligerus to create a double mutant with defects in production of both cephamycin C and clavams. Production of both cephamycin C and non-clavulanic acid clavams was eliminated in the double mutant, and clavulanic acid titers increased about 10% relative to those of the parental strain. This represents the first report of the successful use of genetic engineering to eliminate undesirable metabolic pathways in an industrial strain used for the production of an antibiotic important in human medicine.

Comparison between vaginal misoprostol and cervical dinoprostone for cervical ripening and labor induction.

OBJECTIVE: To compare the efficacy of intravaginal misoprostol (Cytotec) to intracervical dinoprostone (Prepidil) for pre-induction cervical ripening. METHODS: Sixty-one patients admitted for induction of labor, whose cervices were unfavorable (Bishop score: 4), were randomly assigned to either intravaginal placement of a 50 micrograms misoprostol tablet or intracervical administration of dinoprostone gel. RESULTS: Eighteen women (56%) in the misoprostol group and five (17%) in the dinoprostone group achieved cervical ripening within 12 hours (P = 0.007). Fewer doses of misoprostol were required to achieve cervical ripening, and the interval from induction of labor to delivery was shorter in the misoprostol group. Sixteen patients (50%) in the misoprostol group required oxytocin, whereas 26 (90%) in the dinoprostone group required oxytocin augmentation (P = 0.008). There was no significant difference in mode of delivery or neonatal outcome between the two groups. CONCLUSION: Vaginal misoprostol appears to be a more effective cervical ripening agent than cervical dinoprostone.

Patterns of cardiovascular pathology induced by diverse cardioactive drugs.

In the beagle dog, exaggerated hypotension and tachycardia following administration of high doses of vasodilating antihypertensive drugs are associated with vascular injury and characteristic patterns of myocardial necrosis and haemorrhage. Cardiac and vascular inflammation and necrosis also occur in dogs in association with different functional changes including severe hypertension and the effects that follow treatment with high doses of vasoconstrictor and pressor drugs. More recently, cardioactive drugs of novel classes such as the endothelin antagonists have also been shown to produce vascular damage in the beagle dog but in the absence of ischaemic myocardial damage or significant haemodynamic alterations that typically follow administration of high doses of vasodilating antihypertensive or pressor drugs. This underlines the importance of a careful analysis of the patterns of cardiovascular pathology, their dose, temporal and spatial relationships in the context of functional changes.

First-postgraduate-year resident clinical time use on three specialty rotations.

OBJECTIVE: To compare in-hospital time uses by first-postgraduate-year (PGY1) residents during rotations in emergency medicine (EM), internal medicine (IM), and surgery (S). This article reports the clinical components of residency time use. METHODS: A cross-sectional, observational study of the clinical activities of EM PGY1 residents was performed while the residents were on duty during the three specialty rotations. The activities were recorded by an observer using a log with predetermined categories for clinical activities. A time-blocked, convenience sample of resident shifts was observed for each service rotation. The sample was proportional to the total number of hours for which a PGY1 resident was expected to be in the hospital during a rotation on that service. No attempt was made to sample the same resident at all time periods or on all rotations. Proportions were compared by chi2; alpha = 0.0001. RESULTS: Twelve PGY1 residents were observed for a total of 166 hours on S, 156 hours on IM, and 120 hours on EM. These hourly amounts were representative of a typical two-week span of service on each rotation for the residents. On average, the residents spent 57% of their time on clinical or service-oriented activities. During EM and IM rotations, the residents spent most of their time performing clinical information gathering and engaging in case management and data synthesis (52% of total clinical effort). Within this category, residents on EM were more involved with case discussion and review of ancillary test results than on IM (34% vs 20% of time in this category). Conversely, proportionately less time in this category was devoted to documentation on the EM vs IM rotation (56% vs 80%; p < 0.0001). The greatest opportunity to perform procedures was on the S rotation (31% of total clinical time vs 6% for other specialties; p < 0.0001). CONCLUSION: Awareness of the clinical activities performed on PGY1 rotations can help residency directors anticipate educational needs to balance their residents' experience. Since 29% and 42% of total clinical time on PGY1 EM and IM rotations, respectively, is focused on documentation, efforts to enhance charting skills and efficiency are warranted. Also, efforts to enhance PGY1 procedural experience outside of the S rotation appear warranted.

Patterns of drug-induced cardiovascular pathology in the beagle dog: relevance for humans.

In toxicity studies, the examination of tissue sections for pathological changes is the principle method for the identification of organ toxicity and characterisation of the hazard of novel drugs for humans. Study of the patterns of pathological alterations also represents an important means of developing an understanding of the mechanism of toxicity. However as pathological change frequently represents a final common expression of diverse processes, additional functional information is often required for a clear understanding of the mechanisms of toxicity. This is exemplified in the evaluation of the effects of drugs on the beagle dog cardiovascular system where an understanding of mechanisms is crucial in the assessment of human risk. Particular patterns of drug-induced structural change in the myocardium or blood vessels are frequently linked to specific mechanisms of toxicity. However, assessment based on the interpretation of patterns of cardiovascular pathology alone may be misleading. Quite different changes in cardiac and vascular function or direct cellular toxicity may also be manifest by pathological features in common. Therefore, a clear understanding of mechanism frequently requires additional in vivo or in vitro physiological, pharmacological, biochemical or other mechanistic information. The beagle dog remains an important model for the study of cardiovascular toxicity because in this species, haemodynamic changes and pathological alterations can be related in a way that provides the basis for the safe study in humans of novel drugs with cardiovascular activity.

Analysis of a commercially improved Penicillium chrysogenum strain series: involvement of recombinogenic regions in amplification and deletion of the penicillin biosynthesis gene cluster.

Several commercially improved strains of Penicillium chrysogenum have been shown to carry amplifications of the entire penicillin biosynthesis gene cluster. Analysis previously carried out using the strain BW 1890 has here been extended to the characterisation of other members of the SmithKline Beecham strain improvement series. We have determined the length of the amplicon to be 57.4 kb and shown a general increase in copy number and penicillin titre through the series. Sequence analyses of the promoter regions of the acvA, ipnA and aat genes in the high titre strain BW 1901, and comparisons with wild-type sequences have not identified any potentially titre-enhancing mutations. In addition, cDNA screening has failed to identify any further transcribed elements within the co-amplified region. The homogeneity of hybridisation patterns and the identification and analysis of a single copy revertant has shown that the amplification is of a direct tandem nature and we propose a model of chromatid misalignment and recombination as its mode of generation. Hybridisation analysis of penicillin non-producing mutants has indicated the loss, in all those investigated, of the entire penicillin biosynthesis gene cluster, similarities between the deletion junctions in these strains and comparison with previously published data indicating the presence of recombinogenic regions flanking the penicillin biosynthesis gene cluster.

Home care accreditation with the community health accreditation program: part II: the process.

The CHAP accreditation process provides an external, objective marker for the clients served by an agency. This marker indicates that the agency has met national standards of organizational strength and quality. The process results in a detailed analysis of the organization's overall strengths and weaknesses and provides expert consultation regarding findings. This ongoing consultative relationship between CHAP staff members and/or site visitors and agency leadership provides a continued framework for organizational expansion and change to meet ever-changing health-care needs.

The evaluation of potential human carcinogens: a histopathologist's point of view.

Over 100 marketed drugs induce neoplasia when administered at high doses to rats and mice for periods of up to two years. Despite their diverse chemical structures and biological activities, these compounds produce a relatively limited range of tumour types in rodents, most commonly in the liver. Tumours usually develop only after long periods of time following high exposure to drug. The main exceptions are DNA-reactive anticancer drugs such as alkylating agents which produce tumours rapidly in rodents in several organs. In this laboratory, mouse carcinogenicity studies are performed using the C57BL/10J strain. This strain infrequently develops hepatic tumours spontaneously but it is sensitive to the effects of DNA-reactive carcinogens. Moreover, hepatic neoplasms regularly develop in male but not female C57BL/10J mice following long-term treatment with nongenotoxic drugs that produce hepatic enlargement associated with diverse hepatocellular effects. Studies in this strain with the tumorigenic liver enlarger, phenobarbitone, have shown that although such liver enlargement is characterised by a brief burst of hepatocyte replication, this is associated with persistent regional modulation of hepatic growth stimulatory and inhibitory factors and their associated receptors. These findings indicate that there is a sustained alteration to the internal hepatic environment characterised by regional alterations to the balance of hepatocyte mitogens and inhibitors of replication and their respective receptors. Thus, the development of hepatocellular tumours in C57BL/10J mice following two-year treatment with nongenotoxic drugs appears to be a regular response of an organ to an exaggerated and long-term disruption of its homeostasis. Agents that produce tumours in rodents in this way seem likely to pose little or no risk to humans if administered under appropriate clinical circumstances at doses which show no significant disruption of organ homeostasis. However, drugs that produce this type of response need to be distinguished from those that induce unusual and rapid patterns of tumour development because these agents may have high tumorigenic potency of potential hazard to humans.

Two-year carcinogenicity study of tamoxifen in Alderley Park Wistar-derived rats.

Tamoxifen, a nonsteroidal antiestrogen used widely in the treatment of breast cancer, was tested in a conventional 2-year carcinogenicity bioassay in rats, a species in which tamoxifen acts variably as a partial agonist and antagonist on different target tissues. Groups of 51 males and 52 females were given 5, 20, and 35 mg/kg of tamoxifen/day by gastric intubation in 0.5% hydroxypropyl methylcellulose at 5 ml/kg dose volume. There were 102 male and 104 female controls dosed with vehicle alone. Growth rate and food consumption were reduced in all treated groups. The major finding was a dose-related increase in the incidence of hepatocellular tumors which were first observed after 31 weeks of treatment in the top dose group. The majority of the neoplasms were hepatocellular carcinomas showing a well differentiated trabecular pattern. Some tumors were glandular in type. Mortality was increased in the 20 and 35 mg/kg dose groups compared with controls as a result of these tumors. By contrast, survival was greater than controls in rats given 5 mg/kg tamoxifen despite the presence of hepatocellular tumors due to a reduction in the number of pituitary tumors in females and less chronic renal disease in males. The mechanism of hepatic tumor induction by tamoxifen in rats is unclear. In view of the lack of genotoxic activity in conventional genotoxicity studies and lack of similar effect in mice or in humans, the findings may relate to a particular constellation of effects in rats. All other drug-induced changes in this study were nonneoplastic in nature and most appeared to be the result of hormonal perturbation since they were confined to endocrine organs or have been seen previously in rats treated for long periods with tamoxifen.