Familial clustering of dysbiotic oral and fecal microbiomes in juvenile dermatomyositis.

Juvenile dermatomyositis (JDM) is a rare immune-mediated disease of childhood with putative links to microbial exposures. In this multi-center, prospective, observational cohort study, we evaluated whether JDM is associated with discrete oral and gut microbiome signatures. We generated 16S rRNA sequencing data from fecal, saliva, supragingival, and subgingival plaque samples from JDM probands (n = 28). To control for genetic and environmental determinants of microbiome community structure, we also profiled microbiomes of unaffected family members (n = 27 siblings, n = 26 mothers, and n = 17 fathers). Sample type (oral-vs-fecal) and nuclear family unit were the predominant variables explaining variance in microbiome diversity, more so than having a diagnosis of JDM. The oral and gut microbiomes of JDM probands were more similar to their own unaffected siblings than they were to the microbiomes of other JDM probands. In a sibling-paired within-family analysis, several potentially immunomodulatory bacterial taxa were differentially abundant in the microbiomes of JDM probands compared to their unaffected siblings, including Faecalibacterium (gut) and Streptococcus (oral cavity). While microbiome features of JDM are often shared by unaffected family members, the loss or gain of specific fecal and oral bacteria may play a role in disease pathogenesis or be secondary to immune dysfunction in susceptible individuals.

Qualitative Case Study: A Pilot Program to Improve the Integration of Care in a Vulnerable Inner-City Community.

Introduction: There is a strong correlation between vulnerable populations and poor health outcomes. Growing evidence suggests that person-centred interventions using 'link workers' can support communities to navigate and engage with health and community services, leading to improved health service access. We describe the initial phase and qualitative evaluation of a Healthy Living Program, supported by a link worker role. The Program aimed to improve health service access for residents of an Australian inner-city suburb. Methods: To inform future program development, semi-structured interviews were conducted with clients and stakeholders (n = 21). The interviews were analysed thematically to understand program impact, success factors, constraints and potential improvements. Results: Key themes relating to impacts were a new model of working with community, improved access to services, and responsiveness to community need. Key factors for success included being a trusted, consistent presence, having knowledge of the community and health system, and successful engagement with the community and stakeholders. The constraints included difficulty influencing health system change and lack of community input. Suggested improvements were expanding the service, enhancing health system change and increasing community involvement. Conclusion: Knowledge gained from this study will inform future integrated approaches in health districts to address health inequities in areas of need.

What do consumers with chronic conditions expect from their interactions with general practitioners? A qualitative study of Australian consumer and provider perspectives.

BACKGROUND: More than half of Australian adults manage one or more chronic conditions through ongoing interactions with general practitioners (GPs). Their experience of general practice interactions has important implications for their health outcomes and is thus important to explore in-depth. Consumer expectations have emerged as a key consideration in this regard. How well they met in care settings can inform consumers' satisfaction and response to the care received. However, consumer expectations in Australian general practice are not well researched. OBJECTIVE: To identify key consumer expectations in clinical interactions in Australian general practice based on consumer and GP perspectives. DESIGN: Qualitative, phenomenological approach using thematic analysis of semi-structured interviews. SETTING AND PARTICIPANTS: Thirty-one participants: 18 patients with one or more chronic (persisting > 6 months) conditions, 10 GPs and 3 GP registrars in Sydney, Australia. RESULTS: Consumer expectations were strongly related to the context of their ongoing therapeutic relationship with a regular GP. Themes relating to some of the most commonly reported consumer expectations were as follows: (a) the importance of longevity and continuity; (b) having good rapport; (c) GP's respect for consumer opinions and expertise; (d) having effective communication; and (e) addressing mental health. CONCLUSION: Australian GPs and consumers prioritize a positive, long-term clinical relationship in which they respect one another and can communicate their expectations freely. This has implications for consumer satisfaction and in turn ensuring relational continuity, which is particularly relevant to the ongoing care and management of consumers with chronic conditions.

How to implement patient experience surveys and use their findings for service improvement: a qualitative expert consultation study in Australian general practice.

Objective: To identify barriers (patient, provider, practice and system levels) to consider when implementing patient experience surveys in Australian general practice and enablers of their systematic use to inform service improvement in clinical practice as well as the broader health system. Methods and analysis: An expert consultation and qualitative content analysis of cross-sectional, open-text survey data. Data were collected from key international and Australian experts in the areas of measurement and quality improvement in general practice. Results: Responses from 20 participants from six countries were included in the study. Participants discussed the importance of ensuring value and relevance of surveys to stakeholders. Lack of resources, IT infrastructure, capacity building and sustained funding were identified as barriers to implementing surveys. Participants discussed the importance of clearly defining and communicating the purpose of surveys and agreed on the value of using patient experience to inform reflective, team-based learning at the practice level. Opinions differed on the use of patient experience data at the system level, with some questioning its utility or fairness for external performance reporting. Others recommended the aggregation and reporting of these data under certain conditions, including for the purpose of triangulation with other quality and outcome data. The study identified an evidence gap in the assessment and interpretation of patient experience data at the practice and system levels, including the analysis and contextualisation of survey findings at the system level. Conclusion: Patient experience surveys have potential for guiding practice level quality improvement, but many barriers to their implementation remain. There is need for greater research and policy efforts to understand how this information can be used at the system level for improving Australian general practice.

Implementing the Patient Activation Measure (PAM) in clinical settings for patients with chronic conditions: a scoping review.

Objective: The Patient Activation Measure (PAM) assesses the knowledge, skills and confidence of patients to manage their health, and has been consistently used as an outcome measure of health interventions. Using the PAM to tailor interventions to a patient's activation level is less understood. This literature review aimed to examine evidence for interventions using the PAM to tailor care for patients with chronic conditions, including enablers and barriers to implementation, and the impact on quality of care. Methods and analysis: A scoping review methodology was used to identify literature reporting on PAM-tailored interventions. The Insignia Health website and Medline database were searched. Included papers were published in English from 2004 to 2017, from Organisation for Economic Cooperation and Development countries, included adult patients with chronic conditions, and a PAM-tailored intervention. Eligible full-text papers were assessed against the inclusion criteria. Data were extracted into tables and summarised to assess the key findings, recurring themes and differences across papers. Results: Twenty-one papers describing the use of PAM-tailored interventions (n=21) were identified. Interventions included motivational interviewing, health coaching, self-management planning and risk profile assessment. The perceived value and function of the PAM held by organisations, clinicians and patients influenced implementation and use. Evidence for the impact of PAM-tailored interventions on quality of care was limited. Conclusion: The PAM is being used to tailor a range of interventions for patients with chronic conditions. Clinician perceptions and understanding about the PAM's value and purpose influenced implementation. Further research is needed about how PAM-tailored interventions can be integrated into clinical practice, and guide the patient-clinician interaction, in ways that improve the quality of patient care.

What matters to people with chronic conditions when accessing care in Australian general practice? A qualitative study of patient, carer, and provider perspectives.

BACKGROUND: Research underpinning the patient experience of people with chronic conditions in Australian general practice is not well developed. We aimed to ascertain the perspectives of key stakeholders on aspects of patient experience, more specifically with regards to accessing general practice in Australia. METHODS: Using a qualitative design, semi-structured interviews were conducted by telephone and face-to-face with people living with one or more chronic conditions, informal carers, and primary care providers between October 2016 and October 2017. Participants were recruited and selected from three demographically representative primary health networks across Sydney, Australia. Interview transcripts and researcher's reflective fieldnotes were coded and analyzed for key themes of access. Analysis and interpretation of data were guided by Levesque's model of access, a conceptual framework to evaluate access broadly and from corresponding patient- and provider-side dimensions. RESULTS: A total of 40 interviews were included in the analysis. Most participants had attended their general practices for 10 years or more and had regular primary care providers. People with chronic conditions reported access barriers predominantly in their ability to reach services, which were related to illness-related disabilities (limited mobility, chronic pain, fatigue, frailty) and limitations in the availability and accommodation of health services to address patient preferences (unavailability of after-hours services, lack of alternative modes of service delivery). While cost was not a major barrier, we found a lack of clarity in the factors that determined providers' decisions to waive or reduce costs for some patients and not others. CONCLUSIONS: People managing chronic conditions with a long-term primary care provider experienced access barriers in general practice, particularly in their ability to physically reach care and to do so on a timely basis. This study has important policy and practice implications, as it highlights patients' experiences of accessing care and possible areas for improvement to appropriately respond to these experiences. Themes identified may be useful in the design of a patient experience survey tool specific to this population. While it incorporates perspectives from patients, carers and providers, this study could be further strengthened by including perspectives from culturally and linguistically underrepresented patient groups and more carers.

Robotic nurse duties in the urology operative room: 11 years of experience.

The robotic nurse plays an essential role in a successful robotic surgery. As part of the robotic surgical team, the robotic nurse must demonstrate a high level of professional knowledge, and be an expert in robotic technology and dealing with robotic malfunctions. Each one of the robotic nursing team "nurse coordinator, scrub-nurse and circulating-nurse" has a certain job description to ensure maximum patient's safety and robotic surgical efficiency. Well-structured training programs should be offered to the robotic nurse to be well prepared, feel confident, and maintain high-quality of care.

Various upper endoscopic findings of acute esophageal thermal injury induced by diverse food: a case series.

Esophageal thermal injury caused by food has been reported to occur mostly after drinking hot liquid food, and is known to produce alternating white and red linear mucosal bands. In addition, thermal injury caused by ingestion of hot solid foods is documented to be a cause of esophageal ulcers or pseudomembranes. From January 2006 to August 2012, five patients with suspected esophageal thermal injury underwent esophagogastroduodenoscopy with biopsy. A "candy-cane" appearance was observed in one case, pseudomembrane was observed in two cases, an esophageal ulcer was observed in one case, and a friable and edematous mucosa was noted in one case. We believe that the endoscopic findings of esophageal thermal injury depend on the following factors: causative materials, amount of food consumed, exposure period, and time to endoscopy after the incident. Therefore, physicians who encounter patients with suspected esophageal thermal injury should carefully take the patient's history considering these factors.

Prenatal alcohol exposure results in long-term serotonin neuron deficits in female rats: modulatory role of ovarian steroids.

BACKGROUND: Previous studies on male rodents found that prenatal alcohol exposure (PAE) decreases the number of serotonin immunoreactive (5-HT-ir) neurons in the brainstem. However, data on the effects of PAE in females are lacking. In light of known sex differences in responsiveness of the 5-HT system and known effects of estrogen (E2 ) and progesterone (P4 ) in the brain, we hypothesized that sex steroids will modulate the adverse effects of PAE on 5-HT neurons in adult females. METHODS: Adult females from 3 prenatal groups (Prenatal alcohol-exposed [PAE], Pair-fed [PF], and ad libitum-fed Controls [C]) were ovariectomized (OVX), with or without hormone replacement, or underwent Sham OVX. 5-HT-ir cells were examined in key brainstem areas. RESULTS: Our data support the hypothesis that PAE has long-term effects on the 5-HT system of females and that ovarian steroids have a modulatory role in these effects. Intact (Sham OVX) PAE females had marginally lower numbers of 5-HT-ir neurons in the dorsal raphe nucleus of the brainstem compared with PF and C females. This marginal difference became significant following removal of hormones by OVX. Replacement with E2 restored the number of 5-HT-ir neurons in PAE females to control levels, while P4 reversed the effects of E2 . Importantly, despite these differential responses of the 5-HT system to ovarian steroids, there were no differences in E2 and P4 levels among prenatal treatment groups. CONCLUSIONS: These data demonstrate long-term, adverse effects of PAE on the 5-HT system of females, as well as differential sensitivity of PAE compared with control females to the modulatory effects of ovarian steroids on 5-HT neurons. Our findings have important implications for understanding sex differences in 5-HT dysfunction in depression/anxiety disorders and the higher rates of these mental health problems in individuals with fetal alcohol spectrum disorder.

Differential diagnosis of left-sided abdominal pain: primary epiploic appendagitis vs colonic diverticulitis.

AIM: To investigate the clinical characteristics of left primary epiploic appendagitis and to compare them with those of left colonic diverticulitis. METHODS: We retrospectively reviewed the clinical records and radiologic images of the patients who presented with left-sided acute abdominal pain and had computer tomography (CT) performed at the time of presentation showing radiological signs of left primary epiploic appendagitis (PEA) or left acute colonic diverticulitis (ACD) between January 2001 and December 2011. A total of 53 consecutive patients were enrolled and evaluated. We also compared the clinical characteristics, laboratory findings, treatments, and clinical results of left PEA with those of left ACD. RESULTS: Twenty-eight patients and twenty-five patients were diagnosed with symptomatic left PEA and ACD, respectively. The patients with left PEA had focal abdominal tenderness on the left lower quadrant (82.1%). On CT examination, most (89.3%) of the patients with left PEA were found to have an oval fatty mass with a hyperattenuated ring sign. In cases of left ACD, the patients presented with a more diffuse abdominal tenderness throughout the left side (52.0% vs 14.3%; P = 0.003). The patients with left ACD had fever and rebound tenderness more often than those with left PEA (40.0% vs 7.1%, P = 0.004; 52.0% vs 14.3%, P = 0.003, respectively). Laboratory abnormalities such as leukocytosis were also more frequently observed in left ACD (52.0% vs 15.4%, P = 0.006). CONCLUSION: If patients have left-sided localized abdominal pain without associated symptoms or laboratory abnormalities, clinicians should suspect the diagnosis of PEA and consider a CT scan.

Is there a difference in the prevalence of gastroesophageal reflux disease between peritoneal dialysis and hemodialysis patients?

BACKGROUND/AIMS: Gastroesophageal reflux disease (GERD) is a common upper gastrointestinal disorder in patients with chronic kidney disease (CKD). However, little is known about the prevalence of GERD in dialysis patients. The aim of the present study was to investigate the difference in the prevalence of GERD in peritoneal dialysis and hemodialysis patients. METHODS: From July 2010 to August 2011, peritoneal dialysis patients (n=30) and hemodialysis patients (n=38) were enrolled. The prevalences of GERD were assessed at a single center with endoscopic findings and interviews using a questionnaire. Also, risk factors of GERD were evaluated. RESULTS: The prevalences of GERD in peritoneal dialysis and hemodialysis patients were 33.3% and 39.5% (p=0.748), respectively. The prevalences of erosive reflux esophagitis (ERD) in peritoneal dialysis and hemodialysis patients were 16.7% and 23.7% (p=0.477), respectively. The prevalences of nonerosive reflux disease (NERD) in peritoneal dialysis and hemodialysis patients were 16.7% and 13.2% (p=0.685), respectively. The prevalences of GERD, ERD and NERD were higher than those of the general population. The risk factor for GERD was age in hemodialysis patients. CONCLUSIONS: The prevalence of GERD in dialysis patients was higher than that in the general population. However, there was no significant difference between peritoneal dialysis and hemodialysis patients.

Failure and malfunction of da Vinci Surgical systems during various robotic surgeries: experience from six departments at a single institute.

OBJECTIVES: To analyze the mechanical failures and malfunctions of the da Vinci Surgical (S) System during various robotic surgeries in 6 different departments at our institute and also evaluated the solutions for the failures and malfunctions. METHODS: From July 2005 to December 2008, a total of 1797 robotic surgeries were performed at our institute. The surgeries were performed using 4 da Vinci surgical systems (1 standard da Vinci system from July 2005 to July 2007 and 3 da Vinci S systems from July 2007 to December 2008). Mechanical failures or malfunctions occurred in 43 cases. We evaluated the robotic surgeries according to the type of surgery and the department. We analyzed the cases involving conversion to open or laparoscopic surgeries and those in which there was a malfunction with the instrument. RESULTS: There were 43 cases (2.4%) of mechanical failure with the da Vinci system from a total of 1797 robotic surgeries. This included 24 (1.3%) cases of mechanical failure or malfunction and 19 cases (1.1%) of instrument malfunction. The mechanical malfunction included 1 on/off failure, 5 console malfunctions, 6 robotic arm malfunctions, 2 optic system malfunctions, and 10 system errors. One open and 2 laparoscopic conversions (3 cases; 0.17%) were performed. CONCLUSIONS: Mechanical failure or malfunction occurred during robotic surgery in 43 cases (2.4%), and the open or laparoscopic conversion rate during surgery was very low (0.17%). We found the mechanical failure or malfunction to be rare.

Self-inclusion behavior and circular dichroism of aliphatic chain-linked beta-cyclodextrin-viologen compounds and their reduced forms depending on the side of modification.

[Reaction: see text]. The self-inclusion behavior and induced circular dichroism (ICD) characteristics of two beta-cyclodextrin (beta-CD) derivatives, in which a 1-methyl-4,4'-bipyridinium (viologen) group is connected by an octamethylene chain to either the primary (2(2+)) or secondary (3(2+)) side of beta-CD, and of their reduced forms, are investigated. 1H NMR studies showed that 2(2+) forms an intramolecular self-inclusion complex with K(in) = 3.1 +/- 0.4, whereas 3(2+) forms a head-to-head type of dimer with K(D) = 65 +/- 10 M(-1) at 25 degrees C. 2(2+) and 3(2+) form [2]pseudorotaxanes with alpha-CD, with the secondary side of the alpha-CD facing the viologen moiety. The ICD characteristics of mono-6-[4-(1-methyl-4-pyridinio)-1-pyridinio]-beta-CD (1(2+)), 2(2+), 3(2+), and methyloctyl viologen-beta-CD complexes were obtained for the oxidized and reduced states of the viologen units. The results indicated dimer formation for 1 degrees , and intramolecular complexation for 2*+ and 2 degrees in which the reduced viologen units are outside the beta-CD cavity. The results also indicated intramolecular complexation for 3*+ and 3 degrees, but with reduced viologen units inside the cavity. This work provides unequivocal evidence of the preference of the secondary side of cyclodextrins for viologen groups, regardless of their oxidation states, and the dependence of ICD of the viologen chromophores on their location with respect to the CD cavity.

Isomeric [2]rotaxanes and unidirectional [2]pseudorotaxane composed of alpha-cyclodextrin and aliphatic chain-linked carbazole-viologen compounds.

[structure: see text] Capping the alpha-cyclodextrin (alpha-CD) complex of 1-(N-carbazole)-10-[4-(4-pyridinio)-1-pyridinio]decane with 3,5-dimethoxybenzyl bromide in DMF gives two isomeric [2]rotaxanes, 2a and 2b, while alpha-CD and 1-(N-carbazole)-10-[4-(1-methyl-4-pyridnino)-1-pyridinio]decane 3 in water form mostly a unidirectional [2]pseudorotaxane having the same alpha-CD orientation as 2b. Structures were elucidated from 1H NMR and circular dichroism spectra. The orientational specificity of alpha-CD in the 3/alpha-CD [2]pseudorotaxane is due to the slow dethreading rate of the 2b-type isomer.