Background Communication between levels of care can be complex for any patient. For the Servicemember or Veteran with complex medical issues, who needs transitioning between multiple levels of care, this communication involves detailed, individualized information pivotal to quality clinical outcomes and patient/family satisfaction. These complex cases also typically include communication between multiple family members. Purpose The purpose was to summarize the evidence and present recommendations for facilitating effective transitions of patient care within the complex Veterans Affairs (VA) Polytrauma System of Care. Design Evidence Based Review. Methods Selected members of the VA Office of Nursing Service Polytrauma Field Advisory Committee conducted an evidence-based review, and queried a clinical panel of polytrauma nursing experts and direct care rehabilitation nurses. Findings Search results, key practice recommendations, a plan of care template, and future plans for dissemination and implementation are presented. Conclusions Communication is a key to success when managing many details and requires both focus and knowledge of larger systems. Clinical Relevance Direct communication, using a standardized approach, is recommended for successful patient transitions.

Fn1 fibrils have long been viewed as continuous fibers composed of extended, periodically aligned Fn1 molecules. However, our live imaging and single-molecule localization microscopy (SMLM) are inconsistent with this traditional view and show Fn1 fibrils composed of roughly spherical nanodomains containing 6-11 Fn1 dimers. As they move toward the cell center, Fn1 nanodomains become organized into linear arrays, wherein nanodomains are spaced at the average periodicity of 105±17 nm. Periodical Fn1 nanodomain arrays can be visualized between cells in culture and within tissues; they are resistant to deoxycholate treatment and retain nanodomain periodicity in the absence of cells. The nanodomain periodicity in fibrils remained constant when probed with antibodies recognizing distinct Fn1 epitopes or combinations of antibodies recognizing epitopes spanning the length of Fn1. FUD, a peptide that binds Fn1 N-terminus and disrupts Fn1 fibrillogenesis, blocks the organization of Fn1 nanodomains into periodical arrays. These studies establish a new paradigm of Fn1 fibrillogenesis.

Fibronectin (Fn1) is an essential ECM glycoprotein important for embryonic development and homeostasis. The functions of Fn1 in regulating cell fate decisions, morphogenesis and cellular responses to injury are intimately linked to the process of Fn1 fibrillogenesis. Therefore, understanding the mechanisms by which Fn1 proteins assemble into fibrils is necessary to gain insights into diverse functions of Fn1. Using CRISPR/Cas9 mutagenesis, we generated mice and cell lines wherein a sequence encoding a fluorescent protein (FP) was knocked into the Fn1 locus replacing the termination codon, resulting in the expression of Fn1-FP proteins subject to endogenous regulation. Live imaging and super-resolution microscopy revealed that Fn1 fibrils are not continuous fibers as was thought before, instead, they are comprised of a discontinuous array of small nanodomains. Live imaging showed that Fn1 nanodomains are mobile and that they become arranged into progressively longer linear arrays as they move toward the nucleus in parallel with the rearward actin flow. The organization of Fn1 nanodomains into linear fibrillar arrays but not the formation of Fn1 nanodomains is regulated by the interactions mediated by the Fn1 N-terminal assembly domain. The nanodomain architecture of Fn1 fibrils is observed in multiple contexts: in three-dimensional ECM in vivo, on substrata of different composition and stiffness, and is retained when the linkage of Fn1 fibrils to cells is disrupted. The modular assembly and structure of Fn1 fibrils bears important implications for mechanisms of ECM remodeling and signal transduction.

AIM: Lower gastrointestinal hemorrhage in a patient presenting with diverticulitis shifts the diagnosis from uncomplicated to complicated diverticulitis leading to more aggressive treatment measures. This study sought to determine the demographic characteristics of patients hospitalized with diverticular bleeding and diverticulitis with a focus on identifying factors that predispose to hemorrhage. We aim to use demographic information to elucidate whether hemorrhage in the setting of diverticulitis is more similar mechanistically to diverticular bleeding or diverticulitis. MATERIALS AND METHODS: Inpatient data collected by the Pennsylvania Health Care Cost Containment Council was used to analyze 29,479 hospitalizations spanning from 2002 to 2018 at Philadelphia healthcare institutions where the primary diagnosis for admission was diverticulitis or diverticular bleeding. Age, race, and gender were collected for patients hospitalized with diverticular bleeding, di-verticulitis, and diverticulitis complications. Demographic data from the 2010 US Census was used for comparison. RESULTS: Diverticulitis (n = 20,260) disproportionately affects White individuals (p < 0.0001) while diverticular bleeding (n = 9,219) disproportionately affects Black individuals (p < 0.0001). Of all diverticulitis complications, hemorrhage (n = 1,429) had the highest proportion of Black individuals. Patients admitted for diverticular bleeding tend to be older (75.0 ± 12.1) than patients admitted for diverticulitis (60.2 ± 15.9; p < 0.00001). Among those with complicated diverticulitis, patients with hemorrhage are the oldest (70.2 ± 14.7). CONCLUSION: Patients admitted with diverticulitis complicated by hemorrhage were more similar demographically to patients admitted with diverticular bleeding than those admitted with other forms of diverticulitis. Reframing diverticulitis complicated by hemorrhage as uncomplicated diverticulitis with diverticular bleeding could prompt more appropriate treatment with avoidance of potentially unnecessary antibiotics and imaging.Synopsis: An epidemiological assessment of diverticular bleeding and diverticulitis found that patients admitted with diverticulitis complicated by hemorrhage were more similar demographically to patients admitted with diverticular bleeding than those admitted with other forms of diverticulitis. Because prior studies have suggested that demographic differences between diverticular bleeding and diverticulitis suggest distinct etiologies, we conclude that hemorrhage in the setting of diverticulitis should be treated as a diverticular bleed and not as a complication of diverticulitis itself.

Context. Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) is an extremely indolent subset of noninvasive encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC). These lesions share certain features including a delimiting fibrous capsule, and they are distinguished by detailed histological criteria. Objective. We sought to identify whether tumor capsule thickness differs significantly between NIFTP and noninvasive EFVPTC lesions. We also compared tumor capsule thickness between noninvasive and invasive EFVPTC in order to evaluate its utility as a predictive marker of invasion. Design. Encapsulated follicular thyroid neoplasms with papillary-like nuclear features diagnosed over a 3-year period at a single institution were subcategorized into NIFTP, noninvasive EFVPTC, and invasive EFVPTC based on current diagnostic criteria. Maximum tumor capsule thickness for each lesion was measured. Results. A total of 92 lesions (39 NIFTP, 15 noninvasive EFVPTC, and 38 invasive EFVPTC) were evaluated. Tumor capsule thickness was significantly thinner in NIFTP ( P = .022) and significantly thicker in invasive EFVPTC ( P = .0006) when compared with noninvasive EFVPTC. Conclusions. Tumor capsule thickness may be an additional useful marker when distinguishing between NIFTP and noninvasive EFVPTC. A capsule thickness of greater than 0.2 mm should raise suspicion for EFVPTC and thus prompt more thorough review of the submitted tissue for NIFTP exclusionary criteria. Additionally, if capsular and/or vascular invasion are not present on initial slides of an entirely evaluated capsule of EFVPTC that exceeds 0.5 mm in thickness, the pathologist should order additional tissue levels to ensure that a small focus of invasion is not missed.