Methodology of a Cross-sectional Study Evaluating the Impact of a Novel Mobile Care Team on the Prevalence of Ambulatory Care Sensitive Conditions Presenting to Emergency Medical Services

Introduction

Hospitalization due to ambulatory care sensitive conditions (ACSC) is often used as a proxy measure for access to primary care. The prevalence of ACSC has not been measured in the prehospital setting. Emergency medical services (EMS) are being used by patients who lack access to primary care for ACSC. Many novel models of care have been implemented within Canada and internationally, utilizing paramedics to ease the burden of poor primary care access. Recently, a mobile care team (MCT) consisting of a paramedic/nurse configuration has been deployed in the community of New Waterford, Nova Scotia. The team responds to low acuity 911 calls and follow-up appointments booked by primary care clinicians. This study will identify the prevalence of patients with ACSC presenting to EMS before and after the implementation of MCT and the differences after the implementation of the MCT.

Methods

Secondary data will be collected from the centralized EMS electronic patient care report (ePCR) database. All patients presenting to the ground ambulance with ACSC during the year prior to MCT implementation, all patients presenting to the ground ambulance with ACSC during the year post-MCT implementation, and all patients presenting to the MCT with ACSC will be included for analysis, allowing for a calculation of ACSC prevalence. Descriptive methods will be used for age, sex, primary care practitioner, and ASCS complaints. Prevalence data will be compared via the chi-squared test. A subgroup analysis of age, sex, and individual presenting conditions will also be analyzed using the chi-squared test. Confounding will be dealt with via multivariate logistic regression.

Results

The study results are pending; however, a literature review reveals a paucity of data on ACSC in EMS.

Conclusions

Due to the paucity of literature surrounding ACSC prevalence in EMS, the methodology developed to study these prevalence rates is a novel protocol of importance to prehospital research and the epidemiology of ACSC more broadly.

Abstract 3348: The role of SOX2 in promoting resistance to AR-targeted therapies in prostate cancer

Prostate cancer is the most common type of cancer in men, with approximately 181,000 new cases diagnosed in 2016. Due to the central role of the androgen receptor (AR) in prostate development and more importantly prostate cancer cell survival and proliferation, strategies targeting AR have been the mainstay therapy for over 70 years. However, despite potent inhibition of AR pathway activation, many patients develop castration-resistant prostate cancer (CRPC). Second-line therapies, such as enzalutamide, has increased overall survival in CRPC, but resistance to these therapies inevitably emerges, suggesting that other pathways apart from AR signalling are contributing to the failure of treatments. We have previously demonstrated that SOX2 [SRY (sex determining region Y)-box 2] is an AR-repressed gene that is expressed in a large percentage of high Gleason grade prostate tumours, as well as in most metastases. Additionally, expression of SOX2 within a castration-sensitive cell line is sufficient to enable castration-resistant tumor formation in vivo, and enzalutamide resistance in vitro. In prostate cancer, SOX2 is not found with its normal stem cell co-factors, NANOG and OCT4, leading to the hypothesis that SOX2 is interacting with a novel co-factor in prostate cancer to regulate expression of genes promoting castration-resistance. A chromatin-immunoprecipitation experiment in a castration-resistant prostate cancer cell line was performed to determine if SOX2 binds the same genes and activates similar pathways in prostate cancer as in embryonic stem cells. Approximately half of the SOX2 bound genes in the CRPC cell line were shared with the embryonic stem cell line, and these genes are involved in signalling pathways and maintenance of stem cell pluripotency; the genes bound uniquely in the CRPC cell line are present in pathways involved with metabolic processes. To identify potential binding partners of SOX2, computational analysis of the sites bound by SOX2 in the promoter regions of target genes determined the FOXA1 motif is within close proximity to the SOX2 motif, and the physical interaction of these proteins was confirmed through co-immunoprecipitation. Further understanding of SOX2 target genes and the pathways that SOX2 activates in the presence of enzalutamide will be crucial to identify mechanisms of resistance and enable the development of novel therapies for castration-resistant prostate cancer.

Citation Format: Larischa de Wet, Anthony Williams, Marc Gillard, Steve Kregel, Tzintzuni Garcia, Erin McAuley, Ryan Brown, Donald Vander Griend. The role of SOX2 in promoting resistance to AR-targeted therapies in prostate cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3348.

Perceived peer norms, health risk behaviors, and clustering of risk behaviors among Palestinian youth

Relatively little is known about patterns of health risk behaviors among Middle Eastern youth, including how these behaviors are related to perceived peer norms. In a sample of approximately 2,500 15–24 year old Palestinian youth, perceived engagement of general peers in alcohol consumption, drug use and sexual activity was substantially greater than youths’ own (self-reported) engagement in these activities, suggesting a tendency to overestimate the prevalence of risk-taking behavior among peers. Individual participation in a risk behavior strongly covaries with the perceived levels of both friends’ and peers’ engagement in that behavior (p = 0.00 in each case). In addition, significant clustering of risk behaviors is found: youth who participate in one risk behavior are more likely to participate in others. These findings for a rare representative sample of Middle Eastern youth are strikingly similar to those in the US and Europe. The clustering of behaviors suggests that prevention programs should be structured to deal with a range of connected risk behaviors for which certain youth may be at risk. The findings also suggest that adjusting expectations about peers’ behavior may reduce young Palestinians’ engagement in risk taking.

Health risk behaviours of Palestinian youth: findings from a representative survey

BACKGROUND

There is little systematic information about health risk behaviours among youth in Middle Eastern countries, leaving public health authorities unprepared to deal with emerging public health threats at a time of major social change.

AIM

The Palestinian Youth Health Risk study investigates patterns of risk behaviours among Palestinian youth, their perceptions of the risks and benefits of such behaviours, and the relationship of exposure to violence with mental health and engagement in risk behaviours.

METHODS

We conducted a representative survey among 2500 individuals aged 15-24 years in the West Bank and East Jerusalem, permitting reliable comparison across sex and rural-urban divisions. A stratified 2-stage random sample was drawn from the 2007 population census, with strata formed by crossing the 12 governorates with urban, rural and refugee camp locations. Within strata, 208 survey clusters were sampled with probability proportional to size. Within each cluster, 14 households with youth of the appropriate age were sampled.

RESULTS

Among youth aged 20-24 years, 22.4% of males and 11.6% of females reported trying alcohol; 10.5% of males and 4.3% of females reported trying drugs. Almost one quarter of unmarried youth aged 20-24 years reported any sexual experience. Tobacco use is high, even among younger youth (45.4% of males and 21.2% of females aged 15-19 smoke). Risk behaviours are higher among males, older youth and in urban areas and refugee camps.

CONCLUSION

While smoking is of particular concern, prevention outreach for all behaviours should be directed at subgroups and areas identified as highest risk.

Community engagement for paediatric MDR-TB clinical trials: principles to support ethical trial implementation

The paediatric tuberculosis (TB) prevention and treatment landscape is moving into a new and exciting era, with knowledge from clinical trials offering real benefit to children. Community engagement is key to optimising the success of these trials. However, the clinical profile, epidemiology and social perceptions for paediatric multidrug-resistant TB (MDR-TB) complicate the operationalisation of this community engagement. We reflect on a diversity of recent experiences attempting to implement this type of research and the community engagement around it. We describe four recommendations and argue that these should guide the implementation of the community engagement agenda in the new landscape of paediatric MDR-TB clinical trials. Specifically, we argue for 1) dynamic, long-term continuity in community engagement platforms; 2) tiers of TB and research literacy; 3) multiple separate and joint platforms for holding 'stakes'; and 4) addressing the social/structural implications of family participation. We conclude that community-level stakeholders, such as health workers, parents and children, are willing to collaborate in paediatric MDR-TB clinical trials. Using these recommendations, there is considerable opportunity for effective community engagement in this new era of paediatric MDR-TB research.

The effects of audiovisual distraction on the muscle sympathetic responses to experimental muscle pain

Pain elicited by intramuscular infusion of hypertonic saline solution causes muscle sympathetic nerve activity (MSNA) to increase in some subjects, yet decrease in others. Although the direction of the response is not predictable based on baseline physiological and psychological parameters, we know that it results from sustained functional changes in specific brain regions that are responsible for the behavioral and cardiovascular responses to psychological stressors, as well as those involved in attention. The aim of this study was to investigate whether MSNA responses to experimental muscle pain in humans could be altered with an audiovisual stimulus that served to distract them from the pain. MSNA was recorded from the left common peroneal nerve of 20 young healthy individuals during a 45-min intramuscular infusion of hypertonic saline solution into the ipsilateral tibialis anterior muscle. The distracting stimulus commenced 15 min after the start of the infusion and lasted for 15 min. Fifteen subjects showed an increase in mean burst amplitude of MSNA (to 176.4 ± 7.9% of baseline), while five showed a decrease (to 73.1 ± 5.2% of baseline); distraction had no effect on these profiles. These results indicate that even though the subjects were attending to the audiovisual stimulus, and were presumably distracted from the pain, it failed to alter the MSNA responses to muscle pain.

Transverse slot antennas for high field MRI

Purpose

Introduce a novel coil design using an electrically long transversely oriented slot in a conductive sheet.

Theory and Methods

Theoretical considerations, numerical simulations, and experimental measurements are presented for transverse slot antennas as compared with electric dipole antennas.

Results

Simulations show improved central and average transmit and receive efficiency, as well as larger coverage in the transverse plane, for a single slot as compared to a single dipole element. Experiments on a body phantom confirm the simulation results for a slot antenna relative to a dipole, demonstrating a large region of relatively high sensitivity and homogeneity. Images in a human subject also show a large imaging volume for a single slot and six slot antenna array. High central transmit efficiency was observed for slot arrays relative to dipole arrays.

Conclusion

Transverse slots can exhibit improved sensitivity and larger field of view compared with traditional conductive dipoles. Simulations and experiments indicate high potential for slot antennas in high field MRI. Magn Reson Med 80:1233–1242, 2018. © 2018 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine. This is an open access article under the terms of the Creative Commons Attribution NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

An eight-channel sodium/proton coil for brain MRI at 3 T

The purpose of this work is to illustrate a new coil decoupling strategy and its application to a transmit/receive sodium/proton phased array for magnetic resonance imaging (MRI) of the human brain. We implemented an array of eight triangular coils that encircled the head. The ensemble of coils was arranged to form a modified degenerate mode birdcage whose eight shared rungs were offset from the z-axis at interleaved angles of ±30°. This key geometric modification resulted in triangular elements whose vertices were shared between next-nearest neighbors, which provided a convenient location for counter-wound decoupling inductors, whilst nearest-neighbor decoupling was addressed with shared capacitors along the rungs. This decoupling strategy alleviated the strong interaction that is characteristic of array coils at low frequency (32.6 MHz in this case) and allowed the coil to operate efficiently in transceive mode. The sodium array provided a 1.6-fold signal-to-noise ratio advantage over a dual-nuclei birdcage coil in the center of the head and up to 2.3-fold gain in the periphery. The array enabled sodium MRI of the brain with 5-mm isotropic resolution in approximately 13 min, thus helping to overcome low sodium MR sensitivity and improving quantification in neurological studies. An eight-channel proton array was integrated into the sodium array to enable anatomical imaging.

Mal de Debarquement Syndrome: a survey on subtypes, misdiagnoses, onset and associated psychological features

Introduction

Mal de Debarquement Syndrome (MdDS) is a neurological condition typically characterized by a sensation of motion, that persists longer than a month following exposure to passive motion (e.g., cruise, flight, etc.). The most common form of MdDS is motion triggered (MT). However, recently it has been acknowledged that some patients develop typical MdDS symptoms without an apparent motion trigger. These cases are identified here as spontaneous or other onset (SO) MdDS. This study aimed to address similarities and differences between the MdDS subtypes. Diagnostic procedures were compared and extensive diagnostic guidelines were proposed. Second, potential triggers and associated psychological components of MdDS were revealed.

Methods

This was a retrospective online survey study for MT and SO MdDS patients. Participants were required to respond to a set of comprehensive questions regarding epidemiological details, as well as the diagnostic procedures and onset triggers.

Results

There were 370 patients who participated in the surveys. It is indicated that MdDS is often misdiagnosed; more so for the SO group. In addition to the apparent self-motion, both groups reported associated levels of stress, anxiety and depression.

Discussion

It appears at present that both MdDS subtypes are still poorly recognised. This was the first attempt to evaluate the diagnostic differences between MdDS subtypes and to propose a set of comprehensive diagnostic guidelines for both MdDS subtypes. In addition, the current research addressed that associated symptoms such as stress, anxiety and depression should also be considered when treating patients. We hope this study will help the medical community to broaden their awareness and diagnostic knowledge of this condition.

Electronic supplementary material

The online version of this article (10.1007/s00415-017-8725-3) contains supplementary material, which is available to authorized users.

Long-term evaluation of air sensor technology under ambient conditions in Denver, Colorado

Air pollution sensors are quickly proliferating for use in a wide variety of applications, with a low price point that supports use in high-density networks, citizen science, and individual consumer use. This emerging technology motivates the assessment under real-world conditions, including varying pollution levels and environmental conditions. A seven-month, systematic field evaluation of low-cost air pollution sensors was performed in Denver, Colorado, over 2015-2016; the location was chosen to evaluate the sensors in a high-altitude, cool, and dry climate. A suite of particulate matter (PM), ozone (O3), and nitrogen dioxide (NO2) sensors were deployed in triplicate and were collocated with federal equivalent method (FEM) monitors at an urban regulatory site. Sensors were evaluated for their data completeness, correlation with reference monitors, and ability to reproduce trends in pollution data, such as daily concentration values and wind-direction patterns. Most sensors showed high data completeness when data loggers were functioning properly. The sensors displayed a range of correlations with reference instruments, from poor to very high (e.g., hourly-average PM Pearson correlations with reference measurements varied from 0.01 to 0.86). Some sensors showed a change in response to laboratory audits/testing from before the sampling campaign to afterwards, such as Aeroqual, where the O3 response slope changed from about 1.2 to 0.6. Some PM sensors measured wind-direction and time-of-day trends similar to those measured by reference monitors, while others did not. This study showed different results for sensor performance than previous studies performed by the U.S. EPA and others, which could be due to different geographic location, meteorology, and aerosol properties. These results imply that continued field testing is necessary to understand emerging air sensing technology.

The perception of pre- and post-natal marijuana exposure on health outcomes: A content analysis of Twitter messages

The prevalence of marijuana use during pregnancy ranges from 3-30% , and most of this is for recreational purposes. Marijuana exposure during pregnancy has been linked with low birth weight babies and other adverse child health outcomes. Twitter is a popular news and social networking outlet, and is frequently used to access information about population health and behavior. The primary objective of this study was to investigate the types of messages disseminated on Twitter about marijuana use and infant and maternal health. The secondary objective was to describe the reported health outcomes associated with prenatal and postnatal marijuana use. Tweets were collected from the inception of Twitter (2006) until April 2017. If tweets included links, these links were examined to investigate the source of the message and to clarify the user's intent. In total, 550 tweets were captured, with most tweets (77.6%) having a neutral tweet tone, suggesting uncertainty about the health effects associated with pre- and post-natal marijuana exposure. The sources attached to the original tweets, however, were more likely to report on negative health outcomes. The most common health outcomes associated with prenatal marijuana exposure were: poor brain development (27.3%), inadequate development of the nervous system (23.6%), low birth weight (23.3%), poor behavioral outcomes (21.0%), and infant memory issues (19.3%). The inverse association between marijuana use and the quality and quantity of milk produced by the mother was the most commonly reported tweet for the lactation period.

Synthesized tissue-equivalent dielectric phantoms using salt and polyvinylpyrrolidone solutions

PURPOSE

To explore the use of polyvinylpyrrolidone (PVP) for simulated materials with tissue-equivalent dielectric properties.

METHODS

PVP and salt were used to control, respectively, relative permittivity and electrical conductivity in a collection of 63 samples with a range of solute concentrations. Their dielectric properties were measured with a commercial probe and fitted to a 3D polynomial in order to establish an empirical recipe. The material's thermal properties and MR spectra were measured.

RESULTS

The empirical polynomial recipe (available at https://www.amri.ninds.nih.gov/cgi-bin/phantomrecipe) provides the PVP and salt concentrations required for dielectric materials with permittivity and electrical conductivity values between approximately 45 and 78, and 0.1 to 2 siemens per meter, respectively, from 50 MHz to 4.5 GHz. The second- (solute concentrations) and seventh- (frequency) order polynomial recipe provided less than 2.5% relative error between the measured and target properties. PVP side peaks in the spectra were minor and unaffected by temperature changes.

CONCLUSION

PVP-based phantoms are easy to prepare and nontoxic, and their semitransparency makes air bubbles easy to identify. The polymer can be used to create simulated material with a range of dielectric properties, negligible spectral side peaks, and long T₂ relaxation time, which are favorable in many MR applications. Magn Reson Med 80:413-419, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Near-port air quality assessment utilizing a mobile measurement approach

Mobile monitoring is a strategy to characterize spatially and temporally variable air pollution in areas near sources. EPA's Geospatial Measurement of Air Pollution (GMAP) vehicle - an all-electric vehicle is outfitted with a number of measurement devices to record real-time concentrations of particulate matter and gaseous pollutants - was used to map air pollution levels near the Port of Charleston in South Carolina. High-resolution monitoring was performed along driving routes near several port terminals and rail yard facilities, recording geospatial coordinates and concentrations of pollutants including black carbon, size-resolved particle count ranging from ultrafine to coarse (6 nm-20 μm), carbon monoxide, and nitrogen dioxide. Additionally, a portable meteorological station was used to characterize local conditions. The primary objective of this work was to characterize the impact of port facilities on local scale air quality. The study determined that elevated concentration measurements of black carbon and PM correlated to periods of increased port activity and a significant elevation in concentration was observed downwind of ports. However, limitations in study design prevented a more complete analysis of the port effect.

Analysis of a paediatric orthopaedic network: a six-year experience in the South West of the United Kingdom

PURPOSE

We report our experience of a paediatric orthopaedic network, based on a 'hub and spoke' model, covering the South West of the United Kingdom. We identify the areas of most clinical concern, the effect of the network on stream-lining patient management and the benefits of the network to the clinician.

METHODS

Prospective data were collected from the minutes of the bi-annual meetings of the South West Paediatric Network (UK) between November 2006 and May 2012. Data collected included details of the condition, previous treatment, problems, complications and advice given. Cases continue to be followed up in subsequent meetings.

RESULTS

In total 131 cases were included and hip conditions were discussed most frequently (35.1%). The most common indication for discussion was to support and confirm the local management plan. In total, a mean average of 8.75 cases in total were presented per consultant during the study period, with those within ten to 12 years of starting independent practice presenting the majority. The clinical outcome for patients discussed in this forum was local provision of care in 74%, with transfer to the regional centre in 15.7%. Following advice, 14% of direct referrals were given appropriate advice and avoided a journey to the tertiary centre.

CONCLUSION

The network has enabled local provision of care, reduced the burden of travel on patients and prevented unnecessary referrals to the tertiary centre. Additionally, it provides a mechanism to reassure and educate clinicians.

Utility of intraoperative nerve monitoring in thyroid surgery: 20-year experience with 1418 cases

PURPOSE

The efficacy of intraoperative nerve monitoring is controversial in the literature. This study of a single surgeon's experience seeks to determine if the use of intraoperative nerve monitoring influences recurrent laryngeal nerve injury during thyroid surgery.

METHODS

Six hundred fifty-seven patients with normal pre-operative vocal fold function underwent thyroid surgery without the use of intraoperative nerve monitoring from September 1997 to January 2007, while 761 patients underwent thyroid surgery from February 2007 to February 2016 with routine use of nerve monitoring. Patients were followed for a minimum of 6 months after surgery, and postoperative nerve function was determined by fiberoptic laryngoscopy. A Fisher test was used to determine if nerve injury was statistically different between both groups.

RESULTS

In patients operated on without nerve monitoring, 21 patients were found to have postoperative vocal fold paralysis with nine regaining functioning. In patients operated on with nerve monitoring, 27 were found to have vocal fold dysfunction with 17 regaining function. Fisher test analysis, both with and without patients regaining function, showed no difference in nerve injury between groups (p > 0.05, p > 0.05).

CONCLUSION

Intraoperative monitoring during thyroidectomy may not prevent injury to the recurrent laryngeal nerve.

Characterisation of eppin function: expression and activity in the lung

Eppin is a serine protease inhibitor expressed in male reproductive tissues.

The aim of this study was to investigate the localisation and regulation of eppin expression in myeloid and epithelial cell lines, and explore its potential role as a multifunctional host defence protein.

Using immunohistochemistry and Western blotting, eppin was detected in the lungs of patients with acute respiratory distress syndrome and cystic fibrosis lung disease. Expression of eppin in monocytic cells was unaffected by stimulation with Toll-like receptor agonists, cytokines and hormone receptor agonists. However, upregulated expression and secretion of eppin was observed following treatment of monocytes with epidermal growth factor. Incubation of recombinant eppin with monocytic cells resulted in significant inhibition of lipopolysaccharide-induced chemokine production. Furthermore, eppin inhibited lipopolysaccharide-induced NF-κB activation by a mechanism which involved accumulation of phosphorylated IκBα. In anin vivomodel of lung inflammation induced by lipopolysaccharide, eppin administration resulted in decreased recruitment of neutrophils to the lung with a concomitant reduction in the levels of the neutrophil chemokine macrophage inflammatory protein-2.

Overall, these results suggest a role for eppin outside of the reproductive tract and that eppin may have a role in the innate immune response in the lung.

Longitudinal study of sodium MRI of articular cartilage in patients with knee osteoarthritis: initial experience with 16-month follow-up

OBJECTIVES

To evaluate the potential of sodium MRI to detect changes over time of apparent sodium concentration (ASC) in articular cartilage in patients with knee osteoarthritis (OA).

METHODS

The cartilage of 12 patients with knee OA were scanned twice over a period of approximately 16 months with two sodium MRI sequences at 7 T: without fluid suppression (radial 3D) and with fluid suppression by adiabatic inversion recovery (IR). Changes between baseline and follow-up of mean and standard deviation of ASC (in mM), and their rate of change (in mM/day), were measured in the patellar, femorotibial medial and lateral cartilage regions for each subject. A matched-pair Wilcoxon signed rank test was used to assess significance of the changes.

RESULTS

Changes in mean and in standard deviation of ASC, and in their respective rate of change over time, were only statistically different when data was acquired with the fluid-suppressed sequence. A significant decrease (p = 0.001) of approximately 70 mM in mean ASC was measured between the two IR scans.

CONCLUSION

Quantitative sodium MRI with fluid suppression by adiabatic IR at 7 T has the potential to detect a decrease of ASC over time in articular cartilage of patients with knee osteoarthritis.

KEY POINTS

• Sodium MRI can detect apparent sodium concentration (ASC) in cartilage • Longitudinal study: sodium MRI can detect changes in ASC over time • Potential for follow-up studies of cartilage degradation in knee osteoarthritis.

Approaching ultimate intrinsic signal-to-noise ratio with loop and dipole antennas

PURPOSE

Previous work with body-size objects suggested that loops are optimal MR detectors at low fields, whereas electric dipoles are required to maximize signal-to-noise ratio (SNR) at ultrahigh fields ( ≥ 7 T). Here we investigated how many loops and/or dipoles are needed to approach the ultimate intrinsic SNR (UISNR) at various field strengths.

METHODS

We calculated the UISNR inside dielectric cylinders mimicking different anatomical regions. We assessed the performance of various arrays with respect to the UISNR. We validated our results by comparing simulated and experimental coil performance maps.

RESULTS

Arrays with an increasing number of loops can rapidly approach the UISNR at fields up to 3 T, but are suboptimal at ultrahigh fields for body-size objects. The opposite is true for dipole arrays. At 7 T and above, 16 dipoles provide considerably larger central SNR than any possible loop array, and minimal g factor penalty for parallel imaging.

CONCLUSIONS

Electric dipoles can be advantageous at ultrahigh fields because they can produce both curl-free and divergence-free currents, whereas loops are limited to divergence-free contributions only. Combining loops and dipoles may be optimal for body imaging at 3 T, whereas arrays of loops or dipoles alone may perform better at lower or higher field strengths, respectively. Magn Reson Med 79:1789-1803, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Laboratory measurement of the direct oral anticoagulants: Indications and impact on management in clinical practice

Although the direct oral anticoagulants (DOACs) do not require routine laboratory monitoring, there may be special situations in which measurement of drug levels is desirable. There is a paucity of information on how measurement of DOAC levels is used in clinical practice. We conducted a retrospective cohort study of dabigatran, rivaroxaban, and apixaban levels measured at our institution. Of 9793 patients with an active prescription for dabigatran, rivaroxaban, or apixaban in the electronic medical record during the 2.5-year study period, 32 (0.33%) patients underwent a total of 37 DOAC measurements. Twenty patients were on rivaroxaban, 12 were on apixaban, and none was on dabigatran. The most common indications for measurement in inpatients were surgery, breakthrough thrombosis, and bleeding. In the ambulatory setting, patient characteristics suspected to lead to derangements in drug levels (eg, extremes of body weight, gastrointestinal malabsorptive disorders) served as a frequent indication. Among preoperative patients, DOAC levels influenced decisions about the timing of surgery. In most outpatients, levels were within expected ranges and affirmed current management. In a small number of patients with breakthrough thrombosis or bleeding, the identification of drug levels below or above expected concentrations led to a change in the anticoagulant regimen. In conclusion, DOAC measurement was infrequently requested. Indications differed between hospitalized patients and outpatients. Clinical response varied by drug level and indication.

Prophylactic Midface Lift in Midfacial Trauma

The objective was to review our favorable experience in the use of prophylactic midface lifts in the setting of severe midfacial trauma. A retrospective review of a consecutive series of patients undergoing prophylactic midface lifts at the time of definitive fracture repair in a County Hospital Level 1 trauma center was done. All patients undergoing midface lifts at the time of fracture repair by the senior author from July 1998 to July 2012 were included in this review. A total of 72 patients (58 males, 14 females, average age: 36.2 years) were available for review. Sixty-three patients had a minimal follow-up of at least 3 months. No complications felt to be related to the midfacial suspension were noted. There were no instances of frontal nerve paralysis or palsy. There were no patients with ectropion. Patient midfacial symmetry was evaluated by two blinded facial plastic surgeons. It was felt to be excellent in 53 patients, good in 9, fair in 1, and poor in none. The force of trauma necessary to elicit a severe midfacial fracture and the subsequent subperiosteal dissection required to expose the fractures for rigid fixation result in severe laxity of the midfacial soft tissue envelope. Failure to suspend and support these soft tissues will result in significant facial asymmetry. Prophylactic endoscopic midface suspension appears to be a safe and effective method of largely eliminating this problem and should be considered in the setting of severe midfacial fractures.

Dynamic phosphocreatine imaging with unlocalized pH assessment of the human lower leg muscle following exercise at 3T

PURPOSE

To develop a high temporal resolution imaging method that measures muscle-specific phosphocreatine (PCr) resynthesis time constant (τ_PCr ) and pH changes in muscles of the lower leg following exercise on a clinical 3T MRI scanner.

METHODS

We developed a frequency-selective 3D non-Cartesian FLORET sequence to measure PCr with 17-mm nominal isotropic resolution (28 mm actual resolution) and 6-s temporal resolution to capture dynamic metabolic muscle activity. The sequence was designed to additionally collect inorganic phosphate spectra for pH quantification, which were localized using sensitivity profiles of individual coil elements. Nineteen healthy volunteers were scanned while performing a plantar flexion exercise on an in-house developed ergometer. Data were acquired with a dual-tuned multichannel coil array that enabled phosphorus imaging and proton localization for muscle segmentation.

RESULTS

After a 90-s plantar flexion exercise at 0.66 Hz with resistance set to 40% of the maximum voluntary contraction, τ_PCr was estimated at 22.9 ± 8.8 s (mean ± standard deviation) with statistical coefficient of determination r²  = 0.89 ± 0.05. The corresponding pH values after exercise were in the range of 6.9-7.1 in the gastrocnemius muscle.

CONCLUSION

The developed technique allows measurement of muscle-specific PCr resynthesis kinetics and pH changes following exercise, with a temporal resolution and accuracy comparable to that of single voxel ³¹ P-MRS sequences. Magn Reson Med 79:974-980, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Ternary graph as a questionnaire: a new approach to assessment of quality of life?

This study was prompted by awareness of the importance of research into quality of life (QoL) for patients with diseases of the head and neck, the important part questionnaires currently play in this field, and awareness of the "questionnaire fatigue" experienced by many patients. Our multidisciplinary research group raised coincidental awareness of the widespread use of ternary graphs in the sciences, social sciences, and humanities as a graphical tool for quantitative, semiquantitative, or purely graphical characteristics of ternary mixtures. We explored how the basic properties of ternary graphs could be translated into an interactive electronic tool as an alternative to conventional questionnaires. We have described how this was done, and offered open access to an interactive ternary-graph based (self) assessment tool, specifically designed for the needs of patients with conditions of the head and neck. Finally, have we made open-source code available for those who may wish to adapt or develop the tool for further applications.

Fifty states of self-control: A U.S. statewide examination of the initiation and inhibition dimensions of self-regulation

Individual differences in self-control have been shown to reflect two underlying dimensions: initiation and inhibition. We examined the possibility that degrees of self-control might likewise be modeled at a broader social level, similar to other socio-cultural differences that operate at an individual level (e.g., collectivism). To test this notion, we used a variety of mundane behaviors measured at the level of U.S. states to create inhibitory and initiatory indices of self-control at a collective level. We show that statewide levels of initiatory and inhibitory self-control, despite being correlated with one another, exhibit unique patterns of association with a wide range of outcomes, including homicide, suicide, home foreclosures, divorce, and infidelity. This study represents one of the first attempts to model the dimensional structure of self-control at a social level and supports the utility of conceptualizing self-control as an important socio-cultural variable.

Assessing the Current State of Cognitive Frailty: Measurement Properties

BACKGROUND

Currently, an estimated 25-30% of people ages 85 or older have dementia, with a projected 115 million people worldwide living with dementia by 2050. With this worldwide phenomenon fast approaching, early detection of at-risk older adults and development of interventions focused on preventing loss in quality of life are increasingly important. A new construct defined by the International Consensus Group (I.A.N.A/I.A.G.G) as «cognitive frailty» combines domains of physical frailty with cognitive impairment and provides a framework for research that may provide a means to identify individuals with cognitive impairment caused by nonneurodegenerative conditions. Using the integrative review method of Whittemore and Knafl., 2005 this study examines and appraises the optimal measures for detecting cognitive frailty in clinical populations of older adults.

METHODS

The integrative review was conducted using PubMed, CINAHL, Web of Science, PsycInfo, and ProQuest Dissertations and Theses. From the total 185 articles retrieved, review of titles and key words were conducted. Following the initial review, 168 articles did not meet the inclusion criteria for association of frailty and cognition. Of the 18 fulltext articles reviewed, 11 articles met the inclusion criteria; these articles were reviewed in-depth to determine validity and reliability of the cognitive frailty measures.

RESULTS

Predictive validity was established by the studies reviewed in four main areas: frailty and type of dementia MCI (OR 7.4, 95% CI 4.2-13.2), vascular dementia (OR 6.7, 95% CI 1.6-27.4) and Alzheimer's dementia (OR 3.2, 95% CI 1.7-6.2), frailty and vascular dementia (VaAD) is further supported by the rate of change in frailty x macroinfarcts (r = 0.032, p < 0.001); frailty and the individual domains of cognitive function established with the relationship of neurocognitive speed and change in cognition using regression coefficients; individual components of frailty and individual domains of cognitive function associations inculded slow gait and executive function (β -0.20, p < 0.008 ), attention (β -0.25 p < 0.008), processing speed (β -0.16, p < 0.008), word recall (β - 0.18, p = 0.02), and logical memory (β = 0.04, p =0.04). Weak grip was predictive for changes in executive function (β - 0.16, p =0.008). Physical activity was associated with changes in executive function (β = -0.18, p= 0.02) and word recall (β = 0.17, p= 0.02), individual components of frailty and global cognitive function were found in several studies which included grip strength (r = - 0.51, p < 0.001), gait speed (r = - 0.067, p < 0.001), and exhaustion (β - 0.18, p < 0.008).

CONCLUSIONS

This paper presents the first-known review of the measurement properties for the cognitive frailty construct since the published results from the International Consensus Group (I.A.N.A/I.A.G.G). Evidence presented in this review continues to support the link between physical frailty and cognition with developing validity to support distinct relationships between components of physical frailty and cognitive decline. Results call attention to inconsistencies in reporting of reliability, validity, and heterogeneity in the measurements and operational definition for cognitive frailty. Further research is needed to establish an operational definition and develop psychometrically appropriate clinical measures to construct an understanding of the relationship between physical frailty and cognitive decline.

Aiming to Improve Readmissions Through InteGrated Hospital Transitions (AIRTIGHT): study protocol for a randomized controlled trial

Background

Hospital readmissions remain highly prevalent despite being the target of policies and financial penalties. Evidence comparing the effectiveness and costs of interventions to reduce readmissions is lacking, leaving healthcare systems with little guidance on how to improve quality and avoid costly penalties. Effective interventions likely need to bridge inpatient and outpatient settings, incorporate information technology, and use dedicated providers. Such complex innovations will require rigorous evaluation. The framework of quality improvement research provides an approach that both improves care locally and contributes to closing the current knowledge gaps for readmissions. In this trial, we will study a comprehensive intervention that incorporates these recommendations into an integrated practice unit, called transition services, with an aim of reducing 30-day readmission rates.

Methods/design

We describe a nonblinded, pragmatic, controlled trial with two parallel groups comprising an evaluation of the effect of referral to a provider-led integrated practice unit, inclusive of comprehensive multidisciplinary care, dedicated paramedicine providers, and virtual visits, on 30-day readmission rates for high-risk hospitalized patients. An automated risk-scoring system will randomly generate referrals to either transition services or usual care for 1520 hospitalized patients who score as high-risk for readmission. Transition services will then engage with patients in the hospital setting using a patient navigator and provide bridging outpatient services for the 30 days following discharge. All outcome data are retrieved electronically from administrative medical records. After reapplication of inclusion and exclusion criteria at the time of hospital discharge, analyses will follow the intention-to-treat principle such that patients will be analyzed on the basis of the referral group to which they were initially randomized.

Discussion

The hospital transition program under study is complex and integrates the latest recommendations for readmission reduction strategies. As healthcare systems innovate to address readmissions through such complex interventions, there is significant benefit for stakeholders to have a clear understanding of the potential reach, cost, and real-world effectiveness. The pragmatic methods described here provide a template for conducting quality improvement research that fits seamlessly into existing care delivery and improvement efforts, leading to better-informed strategic decisions and the investments necessary to transform care and value for patients.

Trial registration

ClinicalTrials.gov, NCT02763202. Registered 3 March 2016 (retrospectively registered).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1725-2) contains supplementary material, which is available to authorized users.

Impaired mucus clearance exacerbates allergen-induced type 2 airway inflammation in juvenile mice

BACKGROUND

Type 2 airway inflammation plays a central role in the pathogenesis of allergen-induced asthma, but the underlying mechanisms remain poorly understood. Recently, we demonstrated that reduced mucociliary clearance, a characteristic feature of asthma, produces spontaneous type 2 airway inflammation in juvenile β-epithelial Na⁺ channel (Scnn1b)-transgenic (Tg) mice.

OBJECTIVE

We sought to determine the role of impaired mucus clearance in the pathogenesis of allergen-induced type 2 airway inflammation and identify cellular sources of the signature cytokine IL-13.

METHODS

We challenged juvenile Scnn1b-Tg and wild-type mice with Aspergillus fumigatus and house dust mite allergen and compared the effects on airway eosinophilia, type 2 cytokine levels, goblet cell metaplasia, and airway hyperresponsiveness. Furthermore, we determined cellular sources of IL-13 and effects of genetic deletion of the key type 2 signal-transducing molecule signal transducer and activator of transcription 6 (STAT6) and evaluated the effects of therapeutic improvement of mucus clearance.

RESULTS

Reduced mucociliary allergen clearance exacerbated Stat6-dependent secretion of type 2 cytokines, airway eosinophilia, and airway hyperresponsiveness in juvenile Scnn1b-Tg mice. IL-13 levels were increased in airway epithelial cells, macrophages, type 2 innate lymphoid cells, and T_H2 cells along with increased Il33 expression in the airway epithelium of Scnn1b-Tg mice. Treatment with the epithelial Na⁺ channel blocker amiloride, improving airway surface hydration and mucus clearance, reduced allergen-induced inflammation in Scnn1b-Tg mice.

CONCLUSION

Our data support that impaired clearance of inhaled allergens triggering IL-13 production by multiple cell types in the airways plays an important role in the pathogenesis of type 2 airway inflammation and suggests therapeutic improvement of mucociliary clearance as a novel treatment strategy for children with allergen-induced asthma.

Community Air Sensor Network (CAIRSENSE) project: evaluation of low-cost sensor performance in a suburban environment in the southeastern United States

Advances in air pollution sensor technology have enabled the development of small and low-cost systems to measure outdoor air pollution. The deployment of a large number of sensors across a small geographic area would have potential benefits to supplement traditional monitoring networks with additional geographic and temporal measurement resolution, if the data quality were sufficient. To understand the capability of emerging air sensor technology, the Community Air Sensor Network (CAIRSENSE) project deployed low-cost, continuous, and commercially available air pollution sensors at a regulatory air monitoring site and as a local sensor network over a surrounding ∼ 2 km area in the southeastern United States. Collocation of sensors measuring oxides of nitrogen, ozone, carbon monoxide, sulfur dioxide, and particles revealed highly variable performance, both in terms of comparison to a reference monitor as well as the degree to which multiple identical sensors produced the same signal. Multiple ozone, nitrogen dioxide, and carbon monoxide sensors revealed low to very high correlation with a reference monitor, with Pearson sample correlation coefficient (r) ranging from 0.39 to 0.97, 0.25 to 0.76, and 0.40 to 0.82, respectively. The only sulfur dioxide sensor tested revealed no correlation (r < 0.5) with a reference monitor and erroneously high concentration values. A wide variety of particulate matter (PM) sensors were tested with variable results - some sensors had very high agreement (e.g., r = 0.99) between identical sensors but moderate agreement with a reference PM_2.5 monitor (e.g., r = 0.65). For select sensors that had moderate to strong correlation with reference monitors (r > 0.5), step-wise multiple linear regression was performed to determine if ambient temperature, relative humidity (RH), or age of the sensor in number of sampling days could be used in a correction algorithm to improve the agreement. Maximum improvement in agreement with a reference, incorporating all factors, was observed for an NO₂ sensor (multiple correlation coefficient R² _adj-orig = 0.57, R² _adj-final = 0.81); however, other sensors showed no apparent improvement in agreement. A four-node sensor network was successfully able to capture ozone (two nodes) and PM (four nodes) data for an 8-month period of time and show expected diurnal concentration patterns, as well as potential ozone titration due to nearby traffic emissions. Overall, this study demonstrates the performance of emerging air quality sensor technologies in a real-world setting; the variable agreement between sensors and reference monitors indicates that in situ testing of sensors against benchmark monitors should be a critical aspect of all field studies.