Paediatric palliative home care by general paediatricians: a multimethod study on perceived barriers and incentives

<p>Abstract</p> <p>Background</p> <p>Non-specialist palliative care, as it is delivered by general practitioners, is a basic component of a comprehensive palliative care infrastructure for adult patients with progressive and far advanced disease. Currently palliative care for children and adolescents is recognized as a distinct entity of care, requiring networks of service providers across different settings, including paediatricians working in general practice. In Germany, the medical home care for children and adolescents is to a large extent delivered by general paediatricians working in their own practice. However, these are rarely confronted with children suffering from life-limiting diseases. The aim of this study was therefore to examine potential barriers, incentives, and the professional self-image of general paediatricians with regard to paediatric palliative care.</p> <p>Methods</p> <p>Based on qualitative expert interviews, a questionnaire was designed and a survey among general paediatricians in their own practice (n = 293) was undertaken. The survey has been developed and performed in close cooperation with the regional professional association of paediatricians.</p> <p>Results</p> <p>The results showed a high disposition on part of the paediatricians to engage in palliative care, and the majority of respondents regarded palliative care as part of their profile. Main barriers for the implementation were time restrictions (40.7%) and financial burden (31.6%), sole responsibility without team support (31.1%), as well as formal requirements such as forms and prescriptions (26.6%). Major facilitations were support by local specialist services such as home care nursing service (83.0%), access to a specialist paediatric palliative care consultation team (82.4%), as well as an option of exchange with colleagues (60.1%).</p> <p>Conclusions</p> <p>Altogether, the high commitment to this survey reflects the relevance of the issue for paediatricians working in general practice. Education in basic palliative care competence and communication skills was seen as an important prerequisite for the engagement in paediatric palliative home care. A local network of specialist support on site and a 24/7 on-call service are necessary in order to facilitate the implementation of basic palliative care by paediatricians in their own practice.</p

How reliable is assessment of true vocal cord-arytenoid unit mobility in patients affected by laryngeal cancer? a multi-institutional study on 366 patients from the ARYFIX collaborative group

Purpose: In clinical practice the assessment of the "vocal cord-arytenoid unit" (VCAU) mobility is crucial in the staging, prognosis, and choice of treatment of laryngeal squamous cell carcinoma (LSCC). The aim of the present study was to measure repeatability and reliability of clinical assessment of VCAU mobility and radiologic analysis of posterior laryngeal extension. Methods: In this multi-institutional retrospective study, patients with LSCC-induced impairment of VCAU mobility who received curative treatment were included; pre-treatment endoscopy and contrast-enhanced imaging were collected and evaluated by raters. According to their evaluations, concordance, number of assigned categories, and inter- and intra-rater agreement were calculated. Results: Twenty-two otorhinolaryngologists evaluated 366 videolaryngoscopies (total evaluations: 2170) and 6 radiologists evaluated 237 imaging studies (total evaluations: 477). The concordance of clinical rating was excellent in only 22.7% of cases. Overall, inter- and intra-rater agreement was weak. Supraglottic cancers and transoral endoscopy were associated with the lowest inter-observer reliability values. Radiologic inter-rater agreement was low and did not vary with imaging technique. Intra-rater reliability of radiologic evaluation was optimal. Conclusions: The current methods to assess VCAU mobility and posterior extension of LSCC are flawed by weak inter-observer agreement and reliability. Radiologic evaluation was characterized by very high intra-rater agreement, but weak inter-observer reliability. The relevance of VCAU mobility assessment in laryngeal oncology should be re-weighted. Patients affected by LSCC requiring imaging should be referred to dedicated radiologists with experience in head and neck oncology

How reliable is assessment of true vocal cord-arytenoid unit mobility in patients affected by laryngeal cancer? a multi-institutional study on 366 patients from the ARYFIX collaborative group

Purpose: In clinical practice the assessment of the “vocal cord-arytenoid unit” (VCAU) mobility is crucial in the staging, prognosis, and choice of treatment of laryngeal squamous cell carcinoma (LSCC). The aim of the present study was to measure repeatability and reliability of clinical assessment of VCAU mobility and radiologic analysis of posterior laryngeal extension. Methods: In this multi-institutional retrospective study, patients with LSCC-induced impairment of VCAU mobility who received curative treatment were included; pre-treatment endoscopy and contrast-enhanced imaging were collected and evaluated by raters. According to their evaluations, concordance, number of assigned categories, and inter- and intra-rater agreement were calculated. Results: Twenty-two otorhinolaryngologists evaluated 366 videolaryngoscopies (total evaluations: 2170) and 6 radiologists evaluated 237 imaging studies (total evaluations: 477). The concordance of clinical rating was excellent in only 22.7% of cases. Overall, inter- and intra-rater agreement was weak. Supraglottic cancers and transoral endoscopy were associated with the lowest inter-observer reliability values. Radiologic inter-rater agreement was low and did not vary with imaging technique. Intra-rater reliability of radiologic evaluation was optimal. Conclusions: The current methods to assess VCAU mobility and posterior extension of LSCC are flawed by weak inter-observer agreement and reliability. Radiologic evaluation was characterized by very high intra-rater agreement, but weak inter-observer reliability. The relevance of VCAU mobility assessment in laryngeal oncology should be re-weighted. Patients affected by LSCC requiring imaging should be referred to dedicated radiologists with experience in head and neck oncology

Rare predicted loss-of-function variants of type I IFN immunity genes are associated with life-threatening COVID-19

Background: We previously reported that impaired type I IFN activity, due to inborn errors of TLR3- and TLR7-dependent type I interferon (IFN) immunity or to autoantibodies against type I IFN, account for 15–20% of cases of life-threatening COVID-19 in unvaccinated patients. Therefore, the determinants of life-threatening COVID-19 remain to be identified in ~ 80% of cases. Methods: We report here a genome-wide rare variant burden association analysis in 3269 unvaccinated patients with life-threatening COVID-19, and 1373 unvaccinated SARS-CoV-2-infected individuals without pneumonia. Among the 928 patients tested for autoantibodies against type I IFN, a quarter (234) were positive and were excluded. Results: No gene reached genome-wide significance. Under a recessive model, the most significant gene with at-risk variants was TLR7, with an OR of 27.68 (95%CI 1.5–528.7, P = 1.1 × 10−4) for biochemically loss-of-function (bLOF) variants. We replicated the enrichment in rare predicted LOF (pLOF) variants at 13 influenza susceptibility loci involved in TLR3-dependent type I IFN immunity (OR = 3.70[95%CI 1.3–8.2], P = 2.1 × 10−4). This enrichment was further strengthened by (1) adding the recently reported TYK2 and TLR7 COVID-19 loci, particularly under a recessive model (OR = 19.65[95%CI 2.1–2635.4], P = 3.4 × 10−3), and (2) considering as pLOF branchpoint variants with potentially strong impacts on splicing among the 15 loci (OR = 4.40[9%CI 2.3–8.4], P = 7.7 × 10−8). Finally, the patients with pLOF/bLOF variants at these 15 loci were significantly younger (mean age [SD] = 43.3 [20.3] years) than the other patients (56.0 [17.3] years; P = 1.68 × 10−5). Conclusions: Rare variants of TLR3- and TLR7-dependent type I IFN immunity genes can underlie life-threatening COVID-19, particularly with recessive inheritance, in patients under 60&nbsp;years old

Autoantibodies against type I IFNs in patients with life-threatening COVID-19

Interindividual clinical variability in the course of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is vast. We report that at least 101 of 987 patients with life-threatening coronavirus disease 2019 (COVID-19) pneumonia had neutralizing immunoglobulin G (IgG) autoantibodies (auto-Abs) against interferon-w (IFN-w) (13 patients), against the 13 types of IFN-a (36), or against both (52) at the onset of critical disease; a few also had auto-Abs against the other three type I IFNs. The auto-Abs neutralize the ability of the corresponding type I IFNs to block SARS-CoV-2 infection in vitro. These auto-Abs were not found in 663 individuals with asymptomatic or mild SARS-CoV-2 infection and were present in only 4 of 1227 healthy individuals. Patients with auto-Abs were aged 25 to 87 years and 95 of the 101 were men. A B cell autoimmune phenocopy of inborn errors of type I IFN immunity accounts for life-threatening COVID-19 pneumonia in at least 2.6% of women and 12.5% of men

Volume do recipiente, adubação e sua forma de mistura ao substrato no crescimento inicial de Peltophorum dubium (sprengel) taubert em viveiro

O ensaio comparou três volumes de recipientes, três tipos de adubação e duas formas de mistura do fertilizante ao substrato, no crescimento inicial de plântulas de Peltophorum dubium (Sprengel) Taubert (canafístula) em viveiro, num esquema fatorial 3 x 3 x 2. Foram utilizados tubetes de 100 e 180 cm³ preenchidos com substrato comercial e sacos plásticos de 10 x 15 cm cheios com mistura de solo e vermiculita em partes iguais, fertilizados com fertilizante de liberação lenta (FLL) nas dosagens de 1,75 e 3,5 kg m-3 e com formulação NPK a 1,0 kg m-3 de substrato. As formas de misturas adotadas foram aquelas com base por metro cúbico de substrato ou individualmente para cada recipiente. Na análise destrutiva realizada 12 semanas após a emergência, avaliaram-se o número de folhas, a altura da planta, o diâmetro do coleto e as massas secas da parte aérea, o sistema radicular e o total. Os resultados indicaram que a redução no volume do recipiente causou diminuição na massa seca, diâmetro e altura. O número de folhas, a massa seca da parte aérea e a massa seca total foram semelhantes nas plântulas sob fertilização com NPK, independentemente do volume do recipiente, o que não ocorreu naquelas sob FLL, onde esse parâmetro diminuiu com o volume do recipiente. O cálculo do índice de Dickson após 12 semanas indicou valores superiores em mudas com a forma de mistura convencional em relação à individual e maior naquelas sob fertilização com NPK, em comparação com as sob FLL.This essay compared three container volumes, conventional fertilizer, recommended and half recommended slow release fertilizer, and the way of mixing fertilizer in the substrate on the initial growth of Peltophorum dubium seedlings in a nursery. The statistical design was a randomized factorial 3 x 3 x 2, using 180 and 100 cm³ plugs for containers filled with commercial substrate and plastic bags of 10 x 15 cm filled with soil and vermiculita in equal parts. For fertilization, a slow release fertilizer (FLL) was tested in the dosages of 3.5 and 1.75 kg m-3, as well as NPK in 1.0 kg m-3 of substrate. The adopted mixture form was based on a cubical substrate volume or individually for each container. A destructive analysis was done 12 weeks after emergence, evaluating leaf number, plant height, stem diameter, aerial, radicular system and total dry matter. The results indicated that, during the nursery phase, the reduction of container volume caused a reduction in dry matter, diameter and height. The leaf number, aerial and total dry matter was similar in seedlings under fertilization with NPK independent of container volume, which did not occur in those under FLL, where this parameter decreased with container volume. The calculated Dickson Index indicated superior values in seedlings with the conventional mixture form in relation to the individual one, and the biggest one in those under fertilization with NPK compared to the ones under FLL

First light of the VLT planet finder SPHERE IV : Physical and chemical properties of the planets around HR8799

This is a pre-copyedited, author produced PDF of an article accepted for publication in Astronomy & Astrophysics following peer review. Subject to 12 month's embargo period. Embargo end date: 16 February 2017. The version of record [Bonnefoy, M., 'First light of the VLT planet finder SPHERE, IV. Physical and chemical properties of the planets around HR8799', A&A, 587, A58 (2016), first published online 16 February 2016] is available online at doi http://dx.doi.org/10.1051/0004-6361/201526906Context. The system of four planets discovered around the intermediate-mass star HR8799 offers a unique opportunity to test planet formation theories at large orbital radii and to probe the physics and chemistry at play in the atmospheres of self-luminous young (∼30 Myr) planets. We recently obtained new photometry of the four planets and low-resolution (R∼30) spectra of HR8799 d and e with the SPHERE instrument (paper III). Aims. In this paper (paper IV), we aim to use these spectra and available photometry to determine how they compare to known objects, what the planet physical properties are, and how their atmospheres work. Methods. We compare the available spectra, photometry, and spectral-energy distribution (SED) of the planets to field dwarfs and young companions. In addition, we use the extinction from corundum, silicate (enstatite and forsterite), or iron grains likely to form in the atmosphere of the planets to try to better understand empirically the peculiarity of their spectrophotometric properties. To conclude, we use three sets of atmospheric models (BT-SETTL14, Cloud-AE60, Exo-REM) to determine which ingredients are critically needed in the models to represent the SED of the objects, and to constrain their atmospheric parameters (T eff , log g, M/H). Results. We find that HR8799d and e properties are well reproduced by those of L6-L8 dusty dwarfs discovered in the field, among which some are candidate members of young nearby associations. No known object reproduces well the properties of planets b and c. Nevertheless, we find that the spectra and WISE photometry of peculiar and/or young early-T dwarfs reddened by submicron grains made of corundum, iron, enstatite, or forsterite successfully reproduce the SED of these planets. Our analysis confirms that only the Exo-REM models with thick clouds fit (within 2σ) the whole set of spectrophotometric datapoints available for HR8799 d and e for T eff = 1200 K, log g in the range 3.0-4.5, and M/H=+0.5. The models still fail to reproduce the SED of HR8799c and b. The determination of the metallicity, log g, and cloud thickness are degenerate. Conclusions. Our empirical analysis and atmospheric modelling show that an enhanced content in dust and decreased CIA of H2 is certainly responsible for the deviation of the properties of the planet with respect to field dwarfs. The analysis suggests in addition that HR8799c and b have later spectral types than the two other planets, and therefore could both have lower masses.Peer reviewe