Management of metastatic thyroid cancer in pregnancy: risk and uncertainty

Metastatic thyroid cancer is an uncommon condition to be present at the time of pregnancy, but presents a challenging paradigm of care. Clinicians must balance the competing interests of long-term maternal health, best achieved by iatrogenic hyperthyroidism, regular radioiodine therapy and avoidance of dietary iodine, against the priority to care for the developing foetus, with inevitable compromise. Additionally, epidemiological and cellular data support the role of oestrogen as a growth factor for benign and malignant thyrocytes, although communicating the magnitude of this risk to patients and caregivers, as well as the uncertain impact of any pregnancy on long-term prognosis, remains challenging. Evidence to support treatment decisions in this uncommon situation is presented in the context of a case of a pregnant teenager with known metastatic papillary thyroid cancer and recent radioiodine therapy.

Randomised crossover trial of telemonitoring in chronic respiratory patients (TeleCRAFT trial)

Objective

To assess the impact of home telemonitoring on health service use and quality of life in patients with severe chronic lung disease.

Design

Randomised crossover trial with 6 months of standard best practice clinical care (control group) and 6 months with the addition of telemonitoring.

Participants

68 patients with chronic lung disease (38 with COPD; 30 with chronic respiratory failure due to other causes), who had a hospital admission for an exacerbation within 6 months of randomisation and either used long-term oxygen therapy or had an arterial oxygen saturation (SpO₂) of <90% on air during the previous admission. Individuals received telemonitoring (second-generation system) via broadband link to a hospital-based care team.

Outcome measures

Primary outcome measure was time to first hospital admission for an acute exacerbation. Secondary outcome measures were hospital admissions, general practitioner (GP) consultations and home visits by nurses, quality of life measured by EuroQol-5D and hospital anxiety and depression (HAD) scale, and self-efficacy score (Stanford).

Results

Median (IQR) number of days to first admission showed no difference between the two groups—77 (114) telemonitoring, 77.5 (61) control (p=0.189). Hospital admission rate at 6 months increased (0.63 telemonitoring vs 0.32 control p=0.026). Home visits increased during telemonitoring; GP consultations were unchanged. Self-efficacy fell, while HAD depression score improved marginally during telemonitoring.

Conclusions

Telemonitoring added to standard care did not alter time to next acute hospital admission, increased hospital admissions and home visits overall, and did not improve quality of life in chronic respiratory patients.

Trial registration number

NCT02180919 (ClinicalTrials.gov).

Resident reflections on end-of-life education: a mixed-methods study of the 3 Wishes Project

OBJECTIVE

The objectives of this study were to describe residents' experiences with end-of-life (EOL) education during a rotation in the intensive care unit (ICU), and to understand the possible influence of the 3 Wishes Project.

DESIGN

We enrolled dying patients, their families and 1-3 of their clinicians in the 3 Wishes Project, eliciting and honouring a set of 3 wishes to bring peace to the final days of a critically ill patient's life, and ease the grieving process for families. We conducted semistructured interviews with 33 residents who had cared for 50 dying patients to understand their experiences with the project. Interviews were recorded, transcribed verbatim, then analysed using a qualitative descriptive approach.

SETTING

21-bed medical surgical ICU in a tertiary care, university-affiliated hospital.

RESULTS

33 residents participated from internal medicine (24, 72.7%), anaesthesia (8, 24.2%) and laboratory medicine (1, 3.0%) programmes in postgraduate years 1-3. 3 categories and associated themes emerged. (1) EOL care is a challenging component of training in that (a) death in the ICU can invoke helplessness, (b) EOL education is inadequate, (c) personal connections with dying patients is difficult in the ICU and (d) EOL skills are valued by residents. (2) The project reframes the dying process for residents by (a) humanising this aspect of practice, (b) identifying that family engagement is central to the dying process, (c) increasing emotional responsiveness and (d) showing that care shifts, not stops. (3) The project offers experiential education by (a) intentional role modelling, (b) facilitating EOL dialogue, (c) empowering residents to care in a tangible way and (d) encouraging reflection.

CONCLUSIONS

For residents, the 3 Wishes Project integrated many forms of active learning for residents. Practice-based rather than classroom-based programmes may engage trainees to develop EOL skills transferable to other settings.

AMPK antagonizes hepatic glucagon-stimulated cyclic AMP signalling via phosphorylation-induced activation of cyclic nucleotide phosphodiesterase 4B

Biguanides such as metformin have previously been shown to antagonize hepatic glucagon-stimulated cyclic AMP (cAMP) signalling independently of AMP-activated protein kinase (AMPK) via direct inhibition of adenylate cyclase by AMP. Here we show that incubation of hepatocytes with the small-molecule AMPK activator 991 decreases glucagon-stimulated cAMP accumulation, cAMP-dependent protein kinase (PKA) activity and downstream PKA target phosphorylation. Moreover, incubation of hepatocytes with 991 increases the V_max of cyclic nucleotide phosphodiesterase 4B (PDE4B) without affecting intracellular adenine nucleotide concentrations. The effects of 991 to decrease glucagon-stimulated cAMP concentrations and activate PDE4B are lost in hepatocytes deleted for both catalytic subunits of AMPK. PDE4B is phosphorylated by AMPK at three sites, and by site-directed mutagenesis, Ser304 phosphorylation is important for activation. In conclusion, we provide a new mechanism by which AMPK antagonizes hepatic glucagon signalling via phosphorylation-induced PDE4B activation.

The diabetes drug Metformin decreases hepatic glucose production and activates AMP-activated protein kinase (AMPK). Here the authors provide evidence that AMPK activation antagonizes glucagon signalling by activating PDE4B, lowering cAMP levels and decreasing PKA activation.

Communities of practice and the construction of the professional identities of nurse educators: A review of the literature

OBJECTIVES

To comprehensively review the Community of Practice literature from nursing contexts to explore whether and how these communities contribute to the social construction of nurse educator professional identity.

DESIGN

Due to the wide scope of predominately qualitative literature on the topic, papers were analysed and themed inductively.

DATA SOURCES

CINAHL, MEDLINE, COCHRANE, EBSCO databases, Emerald, Proquest & Google Scholar.

REVIEW METHODS

These online databases were searched for relevant peer-reviewed journal papers in the English language with no date range specified. The search terms 'nurs* educator' and 'nurs* teacher' were combined with each of the terms 'communit* of practice', 'identity' and 'role' resulting in 293 peer-reviewed journal papers. Where abstracts were missing, introductory and background sections were skimmed for related content. Papers that made incidental reference to either professional identity or a Community of Practice were excluded.

RESULTS

In total, 63 primary study or discussion papers were found to have a focus on nurse educator identity and/or communities of practice in healthcare contexts. Papers specifically focused on communities of practice in nursing (n=33) could only be found from the last 10 years (2005-2015). Only five of these focused on nurse educators.

CONCLUSIONS

Community of Practice theory and the professional teaching literature offers collaborative and active ways for nurse educators to further develop their professional identities. Despite the emergence of communities of practice in the nursing literature, further studies are required to explore how such a construct can facilitate the social construction of nurse educator professional identity.

In vivo biocompatibility, clearance, and biodistribution of albumin vehicles for pulmonary drug delivery

The development of clinically acceptable albumin-based nanoparticle formulations for use in pulmonary drug delivery has been hindered by concerns about the toxicity of nanomaterials in the lungs combined with a lack of information on albumin nanoparticle clearance kinetics and biodistribution. In this study, the in vivo biocompatibility of albumin nanoparticles was investigated following a single administration of 2, 20, and 390 μg/mouse, showing no inflammatory response (TNF-α and IL-6, cellular infiltration and protein concentration) compared to vehicle controls at the two lower doses, but elevated mononucleocytes and a mild inflammatory effect at the highest dose tested. The biodistribution and clearance of ¹¹¹In labelled albumin solution and nanoparticles over 48 h following a single pulmonary administration to mice was investigated by single photon emission computed tomography and X-ray computed tomography imaging and terminal biodistribution studies. ¹¹¹In labelled albumin nanoparticles were cleared more slowly from the mouse lung than ¹¹¹In albumin solution (64.1 ± 8.5% vs 40.6 ± 3.3% at t = 48 h, respectively), with significantly higher (P < 0.001) levels of albumin nanoparticle-associated radioactivity located within the lung tissue (23.3 ± 4.7%) compared to the lung fluid (16.1 ± 4.4%). Low amounts of ¹¹¹In activity were detected in the liver, kidneys, and intestine at time points > 24 h indicating that small amounts of activity were cleared from the lungs both by translocation across the lung mucosal barrier, as well as mucociliary clearance. This study provides important information on the fate of albumin vehicles in the lungs, which may be used to direct future formulation design of inhaled nanomedicines.

"Holes in my memories": a qualitative study of men affected by father absence

This qualitative study explored adult men's experiences of father absence. Interviews with 21 men between the ages of 24 and 70 explored narratives of father absence and how the men perceived this influenced their life trajectory. Thematic analysis revealed that these men experienced a range of difficulties and challenges, including episodes of sadness and depression associated with loss and grief for the paternal relationship, self-esteem issues, feelings of anger and rejection, and difficulty forming trusting relationships particularly with other men. This study contributes to understanding mental health issues that can be associated with paternal absence for men.