In this trial involving patients with type 2 diabetes and stable ischemic cardiovascular disease, prompt revascularization was compared with medical therapy, and insulin sensitization was compared ...with insulin provision, with patients stratified according to whether they underwent percutaneous coronary intervention or coronary-artery bypass grafting. Revascularization did not significantly reduce the rate of death from any cause or the rate of major cardiovascular events overall. Insulin sensitization and insulin provision also had similar cardiovascular outcomes.
In patients with type 2 diabetes and stable ischemic cardiovascular disease, revascularization did not significantly reduce the rate of death from any cause or the rate of major cardiovascular events overall, as compared to medical therapy. Insulin sensitization and insulin provision also had similar cardiovascular outcomes.
Patients with type 2 diabetes mellitus have a higher risk of cardiovascular events and death than those without diabetes.
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Few large, randomized trials have addressed the question of the optimal treatment for patients with diabetes and angiographically defined stable ischemic heart disease. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial was designed to test treatment strategies for patients with coronary artery disease and diabetes. Our goal was to address the effects of therapy on the rate of myocardial ischemia, a major cause of death in patients with diabetes, and of insulin resistance, the fundamental mechanism underlying diabetes . . .
Abstract Objective To explore the relationship between gender, native artery diameters, and outcomes of stent revascularization (ST) in the “Claudication: Exercise versus Endoluminal ...Revascularization” trial. Methods A comparative analysis was performed of the impact of gender, age, weight, height, body mass index, and body surface area on revascularization outcomes at baseline and 6 months in 55 arterial segments of aorta, common iliac artery, and external iliac artery (EIA). Results Women demonstrated smaller diameter of the EIA. However, the clinical outcomes of revascularization were not negatively affected by the gender-based differences. Conclusion Gender-based differences are unlikely to significantly impact outcome of ST.
There is a lack of meaningful and sustained community participation in New York City land use decisions and the Uniform Land Use Review Procedure (ULURP) does not require adequate consideration of ...the adverse effects of rezonings. Currently, rezonings often advantage those seeking profit off of real estate development, rather than the interests of existing communities, which has resulted in the displacement of local businesses and residents. Decision-makers and developers frequently overlook or ignore the opinions and expertise of local residents within NYC land uses decisions, which ultimately results in inaccurate neighborhood-level information and the inequitable distribution of power in land use decision-making processes. Community-based organizations (CBOs) often advocate on behalf of residents and inform them of the effects of a ULURP decision. However, they are typically underfunded to do this type of work and/or lack the technical resources to engage with all aspects of ULURP to comprehensively advocate for their community’s interests. The main purpose of this research is to examine the Neighborhoods First Fund's (NFF) role in providing grants for technical resources to CBOs to help build upon community assets in planning and organizing. Through a case study examining a collaboration between NFF and the Bronx Coalition for a Community Vision (BCCV) in response to the City’s announcement of the Jerome Avenue Neighborhood Plan, this thesis uncovers the limitations of ULURP and recommends strategies for effective local participation and power sharing. A key aspect of these recommendations is the need to increase community power in planning and organizing in advance of City-led rezonings, rather than solely in response to them. There are many other flaws and inefficiencies within the ULURP process itself, however, this study examines a model for improving just one aspect of its structure through supporting community engagement and providing technical assistance for community advocacy.
A quarter of acute hospital beds are occupied by persons living with dementia, many of whom have communication problems. Healthcare professionals lack confidence in dementia communication skills, but ...there are no evidence-based communication skills training approaches appropriate for professionals working in this context. We aimed to develop and pilot a dementia communication skills training course that was acceptable and useful to healthcare professionals, hospital patients and their relatives.
The course was developed using conversation analytic findings from video recordings of healthcare professionals talking to patients living with dementia in the acute hospital, together with systematic review evidence of dementia communication skills training and taking account of expert and service-user opinion. The two-day course was based on experiential learning theory, and included simulation and video workshops, reflective diaries and didactic teaching. Actors were trained to portray patients living with dementia for the simulation exercises. Six courses were run between January and May 2017. 44/45 healthcare professionals attended both days of the course. Evaluation entailed: questionnaires on confidence in dementia communication; a dementia communication knowledge test; and participants' satisfaction. Video-recorded, simulated assessments were used to measure changes in communication behaviour.
Healthcare professionals increased their knowledge of dementia communication (mean improvement 1.5/10; 95% confidence interval 1.0-2.0; p<0.001). Confidence in dementia communication also increased (mean improvement 5.5/45; 95% confidence interval 4.1-6.9; p<0.001) and the course was well-received. One month later participants reported using the skills learned in clinical practice. Blind-ratings of simulated patient encounters demonstrated behaviour change in taught communication behaviours to close an encounter, consistent with the training, but not in requesting behaviours.
We have developed an innovative, evidence-based dementia communication skills training course which healthcare professionals found useful and after which they demonstrated improved dementia communication knowledge, confidence and behaviour.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Antibodies to PD-1 protein and to one of its ligands, PD-L1, have shown antitumor activity. Unleashing T cells from inhibitory signals may be a strategy to treat cancers. Autoimmune side effects from ...anti–PD-L1 antibody seem less severe than those from anti–CTLA-4 antibody.
Passive cancer immunotherapy that uses tumor-targeted monoclonal antibodies has achieved broad therapeutic efficacy.
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However, T-cell directed immunotherapy has been less successful.
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Despite the large number of tumor antigens induced by genetic and epigenetic changes found in all cancers, tumors resist immune attack by inducing tolerance among tumor-specific T cells and by expressing ligands that engage inhibitory receptors and dampen T-cell functions within the tumor microenvironment.
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Preclinical and clinical data show that antibody blockade of these immune checkpoints can significantly enhance antitumor immunity.
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Cytotoxic T-lymphocyte–associated antigen 4 (CTLA-4), an inhibitory receptor that down-modulates the initial stages of T-cell activation, was the . . .
A quarter of UK acute hospital beds are occupied by people living with dementia (PLWD). Concerns have been raised by both policy makers and carers about the quality of communication between hospital ...staff and PLWD. PLWD may experience communication impairments such as word finding difficulties, limited ability to construct coherent narratives and difficulties understanding others. Since much healthcare delivery occurs through talk, healthcare professionals (HCPs) and PLWD are likely to experience increased communication barriers. Consistent with this, HCPs report stress and reduced job satisfaction associated with difficulty communicating with PLWD. HCPs face these challenges whilst striving to deliver person-centred care, respecting the autonomy and wishes of the patient before them. However, best practice recommendations in the field tend not to be based on actual interactional evidence. This paper investigates recurring interactional difficulties around HCP requests to carry out health and social care tasks and subsequent reluctance or refusal on the part of PLWD. Using conversation analysis, we examined 41 video recordings of HCP/PLWD interactions collected across three acute inpatient wards. We identify both the nature of the refusals, and any mitigation offered, and explore the requests preceding them in terms of entitlement and contingency. We also explore the nature of HCP requests which precede PLWD agreement with a course of action. We conclude that several features of requests can be seen to precede acceptance, principally the use of higher entitlement requests, and the lowering of contingencies. Our findings underline the importance of examining the contextual interactional detail involved in the negotiation of healthcare, which here leads to an understanding of how design of HCP requests can impact on an important healthcare activity being carried out. They also emphasise the power of conversation analytic methods to identify areas of frequent interactional trouble in dementia care which have not previously been articulated.
•Acute hospital staff need to make requests of their patients living with dementia (83).•Hospital patients living with dementia may refuse important requests in direct ways (85).•This creates a dilemma for staff wishing to deliver respectful and effective care (83).•Some forms of requesting made direct refusal more interactionally relevant (77).•High entitlement requests with lowered contingencies supported request acceptance (83).
IMPORTANCE: Despite the growing popularity of cosmetic procedures, the sociocultural and quality-of-life factors that motivate patients to undergo such procedures are not well understood. OBJECTIVE: ...To estimate the relative importance of factors that motivate patients to seek minimally invasive cosmetic procedures. DESIGN, SETTING, AND PARTICIPANTS: This prospective, multicenter observational study was performed at 2 academic and 11 private dermatology practice sites that represented all US geographic regions. Adult patients presenting for cosmetic consultation or treatment from December 4, 2016, through August 9, 2017, were eligible for participation. EXPOSURES: Participants completed a survey instrument based on a recently developed subjective framework of motivations and a demographic questionnaire. MAIN OUTCOMES AND MEASURES: Primary outcomes were the self-reported most common motivations in each quality-of-life category. Secondary outcomes were other frequently reported motivations and those associated with specific procedures. RESULTS: Of 529 eligible patients, 511 agreed to participate, were enrolled, and completed the survey. Typical respondents were female (440 86.1%), 45 years or older (286 56.0%), white (386 75.5%), and college educated (469 91.8%) and had previously received at least 2 cosmetic procedures (270 52.8%). Apart from motivations pertaining to aesthetic appearance, including the desire for beautiful skin and a youthful, attractive appearance, motives related to physical health, such as preventing worsening of condition or symptoms (253 of 475 53.3%), and psychosocial well-being, such as the desire to feel happier and more confident or improve total quality of life (314 of 467 67.2%), treat oneself or celebrate (284 of 463 61.3%), and look good professionally (261 of 476 54.8%) were commonly reported. Motivations related to cost and convenience were rated as less important (68 of 483 14.1%). Most motivations were internally generated, designed to please the patients and not others, with patients making the decision to undergo cosmetic procedures themselves and spouses seldom being influential. Patients younger than 45 years were more likely to undertake procedures to prevent aging (54 of 212 25.5% vs 42 of 286 14.7% among patients ≥45 years; P < .001). Patients seeking certain procedures, such as body contouring (19 of 22 86.4%), acne scar treatment (36 of 42 85.7%), and tattoo removal (8 of 11 72.7%), were more likely to report psychological and emotional motivations. CONCLUSIONS AND RELEVANCE: This initial prospective, multicenter study comprehensively assessed why patients seek minimally invasive cosmetic procedures. Common reasons included emotional, psychological, and practical motivations in addition to the desire to enhance physical appearance. Differences relative to patient age and procedures sought may need further exploration.
Neurons have recently emerged as essential cellular constituents of the tumour microenvironment, and their activity has been shown to increase the growth of a diverse number of solid tumours
. ...Although the role of neurons in tumour progression has previously been demonstrated
, the importance of neuronal activity to tumour initiation is less clear-particularly in the setting of cancer predisposition syndromes. Fifteen per cent of individuals with the neurofibromatosis 1 (NF1) cancer predisposition syndrome (in which tumours arise in close association with nerves) develop low-grade neoplasms of the optic pathway (known as optic pathway gliomas (OPGs)) during early childhood
, raising the possibility that postnatal light-induced activity of the optic nerve drives tumour initiation. Here we use an authenticated mouse model of OPG driven by mutations in the neurofibromatosis 1 tumour suppressor gene (Nf1)
to demonstrate that stimulation of optic nerve activity increases optic glioma growth, and that decreasing visual experience via light deprivation prevents tumour formation and maintenance. We show that the initiation of Nf1-driven OPGs (Nf1-OPGs) depends on visual experience during a developmental period in which Nf1-mutant mice are susceptible to tumorigenesis. Germline Nf1 mutation in retinal neurons results in aberrantly increased shedding of neuroligin 3 (NLGN3) within the optic nerve in response to retinal neuronal activity. Moreover, genetic Nlgn3 loss or pharmacological inhibition of NLGN3 shedding blocks the formation and progression of Nf1-OPGs. Collectively, our studies establish an obligate role for neuronal activity in the development of some types of brain tumours, elucidate a therapeutic strategy to reduce OPG incidence or mitigate tumour progression, and underscore the role of Nf1mutation-mediated dysregulation of neuronal signalling pathways in mouse models of the NF1 cancer predisposition syndrome.
Abstract
Background
Actors portraying simulated patients are widely used in communication skills training in healthcare, but debates persist over the authenticity of these interactions. However, ...healthcare professionals value simulation‐based training because of the opportunity to think and react in real time, which alternatives cannot provide.
Objective
To describe a method for the use of simulation which maximises authenticity by grounding training in real, observed, patterns of patient communication.
Design
Naturally occurring care interactions were video recorded and analysed using conversation analysis (CA) to identify communication patterns. We focused on sites of recurring interactional trouble as areas for training, and identified more and less effective ways of dealing with these. We used the CA findings to train actors portraying simulated patients, based on the observed interactional patterns.
Settings and Participants
Patients living with dementia and healthcare practitioners (HCPs) on two acute healthcare of the elderly wards in the English East Midlands.
Outcome Measures
One month later HCPs reported using the skills learned in clinical practice. Masked‐ratings of before and after simulated patient encounters confirmed these self‐reports in relation to one key area of training.
Results
The Conversation Analysis Based Simulation (CABS) method used in this setting showed positive results across a range of quantitative and qualitative outcome measures. What is significant for the transferability of the method is that qualitative feedback from trainees highlighted the ability of the method to not only illuminate their existing effective practices, but to understand why these were effective and be able to articulate them to others.
Discussion/Conclusion
While the CABS method was piloted in the dementia care setting described here, it has potential applicability across healthcare settings where simulated consultations are used in communication skills training. Grounding simulated interaction in the observed communication patterns of real patients is an important means of maximising authenticity.
Patient and Public Contribution
The VideOing to Improve dementia Communication Education (VOICE) intervention which piloted the CABS method was developed by a multidisciplinary team, including three carers of people with dementia. People living with dementia were involved in the rating of the before and after video simulation assessments.
Effective and targeted conservation action requires detailed information about species, their distribution, systematics and ecology as well as the distribution of threat processes which affect them. ...Knowledge of reptilian diversity remains surprisingly disparate, and innovative means of gaining rapid insight into the status of reptiles are needed in order to highlight urgent conservation cases and inform environmental policy with appropriate biodiversity information in a timely manner. We present the first ever global analysis of extinction risk in reptiles, based on a random representative sample of 1500 species (16% of all currently known species). To our knowledge, our results provide the first analysis of the global conservation status and distribution patterns of reptiles and the threats affecting them, highlighting conservation priorities and knowledge gaps which need to be addressed urgently to ensure the continued survival of the world’s reptiles. Nearly one in five reptilian species are threatened with extinction, with another one in five species classed as Data Deficient. The proportion of threatened reptile species is highest in freshwater environments, tropical regions and on oceanic islands, while data deficiency was highest in tropical areas, such as Central Africa and Southeast Asia, and among fossorial reptiles. Our results emphasise the need for research attention to be focussed on tropical areas which are experiencing the most dramatic rates of habitat loss, on fossorial reptiles for which there is a chronic lack of data, and on certain taxa such as snakes for which extinction risk may currently be underestimated due to lack of population information. Conservation actions specifically need to mitigate the effects of human-induced habitat loss and harvesting, which are the predominant threats to reptiles.
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