Spatial and Temporal Variability of Saxitoxin-Producing Cyanobacteria in U.S. Urban Lakes

Harmful cyanobacterial blooms (HCBs) are of growing global concern due to their production of toxic compounds, which threaten ecosystems and human health. Saxitoxins (STXs), commonly known as paralytic shellfish poison, are a neurotoxic alkaloid produced by some cyanobacteria. Although many field studies indicate a widespread distribution of STX, it is understudied relative to other cyanotoxins such as microcystins (MCs). In this study, we assessed eleven U.S. urban lakes using qPCR, sxtA gene-targeting sequencing, and 16S rRNA gene sequencing to understand the spatio-temporal variations in cyanobacteria and their potential role in STX production. During the blooms, qPCR analysis confirmed the presence of the STX-encoding gene sxtA at all lakes. In particular, the abundance of the sxtA gene had a strong positive correlation with STX concentrations in Big 11 Lake in Kansas City, which was also the site with the highest quantified STX concentration. Sequencing analysis revealed that potential STX producers, such as Aphanizomenon, Dolichospermum, and Raphidiopsis, were present. Further analysis targeting amplicons of the sxtA gene identified that Aphanizomenon and/or Dolichospermum are the primary STX producer, showing a significant correlation with sxtA gene abundances and STX concentrations. In addition, Aphanizomenon was associated with environmental factors, such as conductivity, sulfate, and orthophosphate, whereas Dolichospermum was correlated with temperature and pH. Overall, the results herein enhance our understanding of the STX-producing cyanobacteria and aid in developing strategies to control HCBs.

Post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic: Analysis of the HERO Registry

Little is known about the mental health consequences of the COVID-19 pandemic in healthcare workers (HCWs). Past literature has shown that chronic strain caused by pandemics can adversely impact a variety of mental health outcomes in HCWs. There is growing recognition of the risk of stress and loss of resilience to HCWs during the COVID-19 pandemic, although the risk of post-traumatic stress disorder (PTSD) symptoms in HCWs during the COVID-19 pandemic remains poorly understood. We wanted to understand the relationship between the COVID-19 pandemic and the risk of PTDS symptoms in HCWs during the COVID-19 pandemic. We surveyed 2038 health care workers enrolled in the Healthcare Worker Exposure Response & Outcomes (HERO) study, which is a large standardized national registry of health care workers. Participants answered questions about demographics, COVID-19 exposure, job burnout, and PTSD symptoms. We characterize the burden of PTSD symptoms among HCWs, and determined the association between high PTSD symptoms and race, gender, professional role, work setting, and geographic region using multivariable regression. In a fully adjusted model, we found that older HCWs were less likely to report high PTSD symptoms compared with younger HCWs. Additionally, we found that physicians were less likely to report high PTSD symptoms compared with nurses. These data add to the growing literature on increased risks of mental health challenges to healthcare workers during the COVID-19 pandemic.

Analysis of Oral Anticoagulant Dosing and Adherence to Therapy Among Patients With Nonvalvular Atrial Fibrillation

Importance

Although reduced doses of direct oral anticoagulants (DOACs) are approved for patients with nonvalvular atrial fibrillation (NVAF) at high risk of bleeding, little is known about dosing accuracy, particularly in patients with renal dysfunction.

Objective

To determine whether underdosing of DOACs is associated with longitudinal adherence to anticoagulation.

Design, Setting, and Participants

This retrospective cohort analysis used data from the Symphony Health claims data set. This national medical and prescription data set comprises 280 million patients and 1.8 million prescribers in the US. Patients included had at least 2 claims for NVAF between January 2015 and December 2017. The dates of analysis for this article were from February 2021 to July 2022.

Exposures

This study included patients with CHA2DS2-VASc scores of 2 or higher who were treated with a dose of DOACs who did and did not meet label-specified criteria for dose reduction.

Main Outcomes and Measures

Logistic regression models examined factors associated with off-label dosing (ie, dosing not recommended by US Food and Drug Administration [FDA] labeling), the association of creatinine clearance with recommended DOAC dosing, and the association of DOAC underdosing and excess dosing with 1-year adherence.

Results

Among the 86 919 patients included (median [IQR] age, 74 [67-80] years; 43 724 men [50.3%]; 82 389 White patients [94.8%]), 7335 (8.4%) received an appropriately reduced dose, and 10 964 (12.6%) received an underdose not consistent with FDA recommendations, meaning that 59.9% (10 964 of 18 299) of those who received a reduced dose received an inappropriate dose. Patients who received off-label doses of DOACs were older (median [IQR] age, 79 [73-85] vs 73 [66-79] years) and had higher CHA2DS2-VASc scores (median [IQR], 5 [4-6] vs 4 [3-6]) compared with patients who received appropriate doses (as recommended by FDA labeling). Renal dysfunction, age, heart failure, and the prescribing clinician being in a surgical specialty were associated with dosing not recommended by FDA labeling. Almost one-third of patients (9792 patients [31.9%]) with creatinine clearance less than 60 mL per minute taking DOACs were either underdosed or excess-dosed not consistent with FDA recommendations. For every 10-unit decrease in creatinine clearance, the odds of the patient receiving an appropriately dosed DOAC was lower by 21%. Treatment with underdosed DOACs was associated with a lower likelihood of adherence (adjusted odds ratio, 0.88; 95% CI, 0.83-0.94) and higher risk of anticoagulation discontinuation (adjusted odds ratio, 1.20; 95% CI, 1.13-1.28) by 1 year.

Conclusions and Relevance

In this study of oral anticoagulant dosing, DOAC dosing that did not follow FDA label recommendations was observed in a substantial number of patients with NVAF, occurred more frequently in patients with worse renal function, and was associated with less-consistent long-term anticoagulation. These results suggest a need for efforts to improve the quality of DOAC use and dosing.

Coordinated Care to Optimize Cardiovascular Preventive Therapies in Type 2 Diabetes: A Randomized Clinical Trial

Importance

Evidence-based therapies to reduce atherosclerotic cardiovascular disease risk in adults with type 2 diabetes are underused in clinical practice.

Objective

To assess the effect of a coordinated, multifaceted intervention of assessment, education, and feedback vs usual care on the proportion of adults with type 2 diabetes and atherosclerotic cardiovascular disease prescribed all 3 groups of recommended, evidence-based therapies (high-intensity statins, angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers [ARBs], and sodium-glucose cotransporter 2 [SGLT2] inhibitors and/or glucagon-like peptide 1 receptor agonists [GLP-1RAs]).

Design, Setting, and Participants

Cluster randomized clinical trial with 43 US cardiology clinics recruiting participants from July 2019 through May 2022 and follow-up through December 2022. The participants were adults with type 2 diabetes and atherosclerotic cardiovascular disease not already taking all 3 groups of evidence-based therapies.

Interventions

Assessing local barriers, developing care pathways, coordinating care, educating clinicians, reporting data back to the clinics, and providing tools for participants (n = 459) vs usual care per practice guidelines (n = 590).

Main Outcomes and Measures

The primary outcome was the proportion of participants prescribed all 3 groups of recommended therapies at 6 to 12 months after enrollment. The secondary outcomes included changes in atherosclerotic cardiovascular disease risk factors and a composite outcome of all-cause death or hospitalization for myocardial infarction, stroke, decompensated heart failure, or urgent revascularization (the trial was not powered to show these differences).

Results

Of 1049 participants enrolled (459 at 20 intervention clinics and 590 at 23 usual care clinics), the median age was 70 years and there were 338 women (32.2%), 173 Black participants (16.5%), and 90 Hispanic participants (8.6%). At the last follow-up visit (12 months for 97.3% of participants), those in the intervention group were more likely to be prescribed all 3 therapies (173/457 [37.9%]) vs the usual care group (85/588 [14.5%]), which is a difference of 23.4% (adjusted odds ratio [OR], 4.38 [95% CI, 2.49 to 7.71]; P < .001) and were more likely to be prescribed each of the 3 therapies (change from baseline in high-intensity statins from 66.5% to 70.7% for intervention vs from 58.2% to 56.8% for usual care [adjusted OR, 1.73; 95% CI, 1.06-2.83]; ACEIs or ARBs: from 75.1% to 81.4% for intervention vs from 69.6% to 68.4% for usual care [adjusted OR, 1.82; 95% CI, 1.14-2.91]; SGLT2 inhibitors and/or GLP-1RAs: from 12.3% to 60.4% for intervention vs from 14.5% to 35.5% for usual care [adjusted OR, 3.11; 95% CI, 2.08-4.64]). The intervention was not associated with changes in atherosclerotic cardiovascular disease risk factors. The composite secondary outcome occurred in 23 of 457 participants (5%) in the intervention group vs 40 of 588 participants (6.8%) in the usual care group (adjusted hazard ratio, 0.79 [95% CI, 0.46 to 1.33]).

Conclusions and Relevance

A coordinated, multifaceted intervention increased prescription of 3 groups of evidence-based therapies in adults with type 2 diabetes and atherosclerotic cardiovascular disease.

Trial Registration

ClinicalTrials.gov Identifier: NCT03936660.

Spinal drain for aortic aneurysm repairs: tool or toy?

PURPOSE OF REVIEW

Spinal cord injury (SCI) is one of the biggest complications in open and endovascular aortic repairs. Historically, cerebrospinal fluid drains (CSFD) have been one of the most effective modalities in reducing SCI and one of the most studied. CSFD placement also carries its' own set of procedural risks. This editorial intends to evaluate recent literature to determine whether CSFDs remain a valuable tool in aortic repair.

RECENT FINDINGS

As the surgical management of thoracic aortic aneurysms has evolved, there has been an increasing number of endovascular repairs. Current recommendations emphasize prophylactic CSFD placement in endovascular repair cases deemed 'high risk.' However, several meta-analyses differ on whether prophylactic CSFD placement reduced the risk of SCI. The incidence of SCI decreased between 2014 and 2018, despite a similar rate of prophylactic CSFD placement suggesting other techniques are being performed and may be effective in spinal cord protection as well.

SUMMARY

There has been conflicting data on whether CSFDs have a role in reducing the risk of SCI in endovascular aortic repair. Some studies suggest that there is no benefit to placement while others suggest that routine prophylactic drains should be placed for all endovascular cases. Despite this, efforts have been made to selectively place CSFDs in those patients deemed at 'high risk' for SCI. CSFDs also remain a part of rescue treatment for postoperative SCI. This suggests that CSFDs continue to be a valuable tool that we need to better comprehend. Future research is necessary to better understand how patient risk factors can be balanced with perioperative management to help identify patients who may benefit from CSFD placement.

Coordinating Cardiology clinics randomized trial of interventions to improve outcomes (COORDINATE) - Diabetes: rationale and design

Several medications that are proven to reduce cardiovascular events exist for individuals with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease, however they are substantially underused in clinical practice. Clinician, patient, and system-level barriers all contribute to these gaps in care; yet, there is a paucity of high quality, rigorous studies evaluating the role of interventions to increase utilization. The COORDINATE-Diabetes trial randomized 42 cardiology clinics across the United States to either a multifaceted, site-specific intervention focused on evidence-based care for patients with T2DM or standard of care. The multifaceted intervention comprised the development of an interdisciplinary care pathway for each clinic, audit-and-feedback tools and educational outreach, in addition to patient-facing tools. The primary outcome is the proportion of individuals with T2DM prescribed three key classes of evidence-based medications (high-intensity statin, angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and either a sodium/glucose cotransporter-2 inhibitor (SGLT-2i) inhibitor or glucagon-like peptide 1 receptor agonist (GLP-1RA) and will be assessed at least 6 months after participant enrollment. COORDINATE-Diabetes aims to identify strategies that improve the implementation and adoption of evidence-based therapies.

Measuring corporate Paris Compliance using a strict science-based approach

The achievement of the Paris Agreement climate goals of well-below 2 degrees of warming requires companies to align their greenhouse gas emission reductions with this goal. To measure whether companies are compliant with the Paris targets we propose several strict conditions that any emissions allocation methodology must meet before it can be classified as Paris-Compliant. Our conditions focus on the need for a common, and early as practicable, base year for all companies and consistency with an underlying Paris-aligned decarbonisation pathway. Additionally, we propose four operationalisation requirements to ensure companies can declare they are on a Paris Compliant Pathway including calculations of their carbon budgets and re-alignment pathways. Applying example Paris-Compliant Pathways and associated metrics to ten high emission electric utility companies and ten cement companies, we find that all but one of these companies are not currently Paris-compliant, with every year of delayed action increasing their required rate of decarbonisation and hence the exposure of billions of investment dollars to transition risk. Applying this proposed method will ensure the Paris carbon budget is met and that progress can be tracked accurately - an imperative for any companies and stakeholders seeking to align their decision-making with the Paris Agreement.

Impact of lactic acid bacteria on the control of Listeria monocytogenes in ready-to-eat foods

Due to the increased demand for ready-to-eat (RTE) minimally processed foods, alternatives to chemical and thermal preservation methods to maintain food safety are highly demanded. A significant safety hazard in RTE food products is the growth of the foodborne pathogen Listeria monocytogenes. After processing, recontamination or cross-contamination of L. monocytogenes in RTE food products may occur and the lack of cooking can lead to an increased risk of listeriosis. Further, some RTE food products (e.g., cheese and cured meat) can have a long processing period and shelf life, thus allowing for the growth and proliferation of L. monocytogenes in the food matrix. Lactic acid bacteria (LAB) are generally recognized as safe (GRAS) probiotics and have been proposed as a biological control approach to eliminate foodborne pathogens including L. monocytogenes. LAB have been reported to extend the shelf life of food products and inhibit pathogen proliferation via growth competition and metabolite production. LAB are native microflora of many RTE foods, but only certain LAB may inhibit pathogen growth. Therefore, specificity of LAB species should be employed into their use in RTE foods. This review will discuss the antimicrobial mechanisms of LAB against L. monocytogenes, selective use of LAB in food matrices, and their uses in food processing and packaging.

The Role of Base Excision Repair in Major Depressive Disorder and Bipolar Disorder

Introduction

In vivo and in vitro studies suggest that inflammation and oxidative damage may contribute to the pathogenesis of major depressive disorder (MDD) and bipolar disorder (BD). Imbalance between DNA damage and repair is an emerging research area examining pathophysiological mechanisms of these major mood disorders.

Objectives

This systematic review sought to examine current evidence on the association between mood disorders and deficits in base excision repair (BER), the primary repair mechanism for repair of oxidation-induced DNA lesions.

Methods

We conducted a comprehensive literature search of Ovid MEDLINE® Epub Ahead of Print, Ovid MEDLINE® In-Process & Other Non-Indexed Citations, Ovid MEDLINE® Daily, EMBASE (1947), and PsycINFO for studies investigating the alterations in base excision repair in patients with MDD or BD.

Results

A total of 1,364 records were identified. 1,352 records remained after duplicates were removed. 24 records were selected for full-text screening and a remaining 12 articles were included in the qualitative synthesis. SNPs (Single Nucleotide Polymorphisms) of several BER genes have been shown to be associated with MDD and BD. However, it was difficult to draw conclusions from BER gene expression studies due to conflicting findings and the small number of studies.

Conclusions

Future studies comparing DNA repair during the manic or depressive episode to remission will give us a better insight regarding the role of DNA repair in mood disorders. These alterations might be utilized as diagnostic and prognostic biomarkers as well as measuring treatment response.

Disclosure

No significant relationships.

A Systematic Review of Automatic Health Monitoring in Calves: Glimpsing the Future From Current Practice

Infectious diseases, particularly bovine respiratory disease (BRD) and neonatal calf diarrhea (NCD), are prevalent in calves. Efficient health-monitoring tools to identify such diseases on time are lacking. Common practice (i.e., health checks) often identifies sick calves at a late stage of disease or not at all. Sensor technology enables the automatic and continuous monitoring of calf physiology or behavior, potentially offering timely and precise detection of sick calves. A systematic overview of automated disease detection in calves is still lacking. The objectives of this literature review were hence: to investigate previously applied sensor validation methods used in the context of calf health, to identify sensors used on calves, the parameters these sensors monitor, and the statistical tools applied to identify diseases, to explore potential research gaps and to point to future research opportunities. To achieve these objectives, systematic literature searches were conducted. We defined four stages in the development of health-monitoring systems: (1) sensor technique, (2) data interpretation, (3) information integration, and (4) decision support. Fifty-four articles were included (stage one: 26; stage two: 19; stage three: 9; and stage four: 0). Common parameters that assess the performance of these systems are sensitivity, specificity, accuracy, precision, and negative predictive value. Gold standards that typically assess these parameters include manual measurement and manual health-assessment protocols. At stage one, automatic feeding stations, accelerometers, infrared thermography cameras, microphones, and 3-D cameras are accurate in screening behavior and physiology in calves. At stage two, changes in feeding behaviors, lying, activity, or body temperature corresponded to changes in health status, and point to health issues earlier than manual health checks. At stage three, accelerometers, thermometers, and automatic feeding stations have been integrated into one system that was shown to be able to successfully detect diseases in calves, including BRD and NCD. We discuss these findings, look into potentials at stage four, and touch upon the topic of resilience, whereby health-monitoring system might be used to detect low resilience (i.e., prone to disease but clinically healthy calves), promoting further improvements in calf health and welfare.

Nosocomial or not? A combined epidemiological and genomic investigation to understand hospital-acquired COVID-19 infection on an elderly care ward

Background

COVID-19 has the potential to cause outbreaks in hospitals. Given the comorbid and elderly cohort of patients hospitalized, hospital-acquired COVID-19 infection is often fatal. Pathogen genome sequencing is becoming increasingly important in infection prevention and control (IPC).

Aim

To inform the understanding of in-hospital SARS-CoV-2 transmission in order to improve IPC practices and to inform the future development of virological testing for IPC.

Methods

Patients detected COVID-19 positive by polymerase chain reaction on Ward A in April and May 2020 were included with contact tracing to identify other potential cases. Genome sequencing was undertaken for a subgroup of cases. Epidemiological, genomic, and cluster analyses were performed to describe the epidemiology and to identify factors contributing to the outbreak.

Findings

Fourteen cases were identified on Ward A. Contact tracing identified 16 further patient cases; in addition, eight healthcare workers (HCWs) were identified as being COVID-19 positive through a round of asymptomatic testing. Genome sequencing of 16 of these cases identified viral genomes differing by two single nucleotide polymorphisms or fewer, with further cluster analysis identifying two groups of infection (a five-person group and a six-person group).

Conclusion

Despite the temporal relationship of cases, genome sequencing identified that not all cases shared transmission events. However, 11 samples were found to be closely related and these likely represented in-hospital transmission. This included three HCWs, thereby confirming transmission between patients and HCWs.

Design of the healthcare worker exposure response and outcomes (HERO) research platform

BACKGROUND

The SARS CoV-2 virus has caused one of the deadliest pandemics in recent history, resulting in over 170 million deaths and global economic disruption. There remains an urgent need for clinical trials to test therapies for treatment and prevention.

DESIGN

An online research platform was created to support a registry community of healthcare workers (HCWs) to understand their experiences and conduct clinical studies to address their concerns. The first study, HERO-HCQ, was a double-blind, multicenter, randomized, pragmatic trial to evaluate the superiority of hydroxychloroquine (HCQ) vs placebo for pre-exposure prophylaxis (PrEP) of COVID-19 clinical infection in HCWs. Secondary objectives were to assess the efficacy of HCQ in preventing viral shedding of COVID-19 among HCWs and to assess the safety and tolerability of HCQ.

METHODS

HCWs joined the Registry and were pre-screened for trial interest and eligibility. Trial participants were randomized 1:1 to receive HCQ or placebo. On-site baseline assessment included a COVID-19 nasopharyngeal PCR and blood serology test. Weekly follow-up was done via an online portal and included screening for symptoms of COVID-19, self-reported testing, adverse events, and quality of life assessments. The on-site visit was repeated at Day 30.

DISCUSSION

The HERO research platform offers an approach to rapidly engage, screen, invite and enroll into clinical studies using a novel participant-facing online portal interface and remote data collection, enabling limited onsite procedures for conduct of a pragmatic clinical trial. This platform may be an example for future clinical trials of common conditions to enable more rapid evidence generation.

Incorporating SGLT2i and GLP-1RA for Cardiovascular and Kidney Disease Risk Reduction: Call for Action to the Cardiology Community

Multiple sodium glucose cotransporter-2 inhibitors (SGLT-2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) have been shown to impart significant cardiovascular and kidney benefits, but are underused in clinical practice. Both SGLT-2i and GLP-1RA were first studied as glucose-lowering drugs, which may have impeded uptake by cardiologists in the wake of proven cardiovascular efficacy. Their significant effect on cardiovascular and kidney outcomes, which are largely independent of glucose-lowering effects, must drive a broader use of these drugs. Cardiologists are 3 times more likely than endocrinologists to see patients with both type 2 diabetes and cardiovascular disease, thus they are ideally positioned to share responsibility for SGLT-2i and GLP-1RA treatment with primary care providers. In order to increase adoption, SGLT-2i and GLP-1RA must be reframed as primarily cardiovascular and kidney disease risk-reducing agents with a side effect of glucose-lowering. Coordinated and multifaceted interventions engaging clinicians, patients, payers, professional societies, and health systems must be implemented to incentivize the adoption of these medications as part of routine cardiovascular and kidney care. Greater use of SGLT-2i and GLP-1RA will improve outcomes for patients with type 2 diabetes at high risk for cardiovascular and kidney disease.

Development and implementation of a clinical information system-based protocol to improve nurse satisfaction of end-of-life care in a single intensive care unit

BACKGROUND

Patients treated in Australian intensive care units (ICUs) have an overall mortality rate of 5.05%. This is due to the critical nature of their disease, the increasing proportion of patients with multiple comorbidities, and advanced age. This has made treating patients during the end of life an integral part of intensive care practice and requires a high quality of care. With the increased use of electronic clinical information systems, a standardised protocol encompassing end-of-life care may provide an efficient method for documentation, communication, and timely delivery of comfort care.

OBJECTIVE

The aim of the study was to determine if an electronic clinical information system-based end-of-life care protocol improved nurses' satisfaction with the practice of end-of-life care for patients in the ICU.

DESIGN

This is a prospective single-centre observational study.

SETTING

The study was carried out at a 20-bed cardiothoracic and general ICU between 2015 and 2017.

PARTICIPANTS

The study participants were ICU nurses.

INTERVENTION

Electronic clinical information-based end-of-life care protocol was used in the study.

OUTCOME

The primary outcome was nurse satisfaction obtained by a survey.

RESULTS

The number of respondents for the before survey and after survey was 58 (29%) and 64 (32%), respectively. There was a significant difference between the before survey and the after survey with regard to feeling comfortable in transitioning from curative treatment (median = 2 [interquartile range {IQR} = 2, 3] vs 3 [IQR = 2, 3], p = 0.03), feeling involved in the decision to move from curative treatment to end-of-life care (median = 2 [IQR = 2, 2] vs 2 [IQR 2, 3], p = 0.049), and feeling religious beliefs/rituals should be respected during the end-of-life process (median = 4 [IQR = 3, 4] vs. 4 [IQR = 4, 4], p = 0.02). There were some practices that had a low satisfaction rate on both the before survey and after survey. However, a high proportion of nurses were satisfied with many of the end-of-life care practices.

CONCLUSION

The nurses were highly satisfied with many aspects of end-of-life care practices in this unit. The use of an electronic clinical information system-based protocol improved nurse satisfaction and perception of quality of end-of-life care practices for three survey questions.

Differences in Preferences Between Clinicians and Patients for the Use and Dosing of Direct Oral Anticoagulants for Atrial Fibrillation

Background Direct oral anticoagulants (DOACs) are effective in reducing the stroke risk for patients with nonvalvular atrial fibrillation if prescribed at the labeled dose, yet underdosing is frequent. Little is known about clinician knowledge and patient or clinician preferences for DOAC dosing. Methods and Results From April 2019 to March 2020, 240 clinicians and 343 patients with atrial fibrillation completed an assessment of anticoagulation knowledge/preferences. Clinician knowledge of DOAC dosing was tested with 4 hypothetical patient scenarios. Patients and clinicians were asked to grade the importance of 25 factors in anticoagulation decision making. Among clinicians, the median age was 55 years, and 23% were primary care clinicians. In scenarios of a patient indicated for full-dose DOAC, 41.2% of clinicians underdosed apixaban and 17.6% underdosed rivaroxaban. In scenarios of a patient indicated for reduced-dose DOAC, 64.6% and 71.7% of clinicians chose to use reduced-dose apixaban and rivaroxaban, respectively. Only 35.0% of clinicians correctly answered all 4 scenarios with the label-indicated dose; this knowledge gap was similar between clinicians who did and did not underdose. Among patients with atrial fibrillation, the median age was 65 years, and 89% were currently anticoagulated. Patients and clinicians ranked stroke prevention and avoiding severe bleeding as very important to anticoagulation decision making. Patients were more likely than clinicians to rank the ability to reduce anticoagulation dose if needed as very important (70.5% versus 43.6%; P<0.001). Conclusions There are considerable knowledge gaps regarding DOAC dosing in clinicians treating patients with atrial fibrillation, as well as significant differences in treatment dosing preferences between clinicians and patients.

HIV prevalence and HIV clinical outcomes of transgender and gender-diverse people in England

OBJECTIVES

We provide the first estimate of HIV prevalence among trans and gender-diverse people living in England and compare outcomes of people living with HIV according to gender identity.

METHODS

We analysed a comprehensive national HIV cohort and a nationally representative self-reported survey of people accessing HIV care in England (Positive Voices). Gender identity was recorded using a two-step question co-designed with community members and civil society. Responses were validated by clinic follow-up and/or self-report. Population estimates were obtained from national government offices.

RESULTS

In 2017, HIV prevalence among trans and gender-diverse people was estimated at 0.46-4.78 per 1000, compared with 1.7 (95% credible interval: 1.6-1.7) in the general population. Of 94 885 people living with diagnosed HIV in England, 178 (0.19%) identified as trans or gender-diverse. Compared with cisgender people, trans and gender-diverse people were more likely to be London residents (57% vs. 43%), younger (median age 42 vs. 46 years), of white ethnicity (61% vs. 52%), under psychiatric care (11% vs. 4%), to report problems with self-care (37% vs. 13%), and to have been refused or delayed healthcare (23% vs. 11%). Antiretroviral uptake and viral suppression were high in both groups.

CONCLUSIONS

HIV prevalence among trans and gender-diverse people living in England is relatively low compared with international estimates. Furthermore, no inequalities were observed with regard to HIV care. Nevertheless, trans and gender-diverse people with HIV report poorer mental health and higher levels of discrimination compared with cisgender people.

Health resource utilization of labor induction versus expectant management

BACKGROUND

Although induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization.

OBJECTIVE

The objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum.

STUDY DESIGN

This is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum.

RESULTS

Of 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all).

CONCLUSION

Women randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.

Hip resurfacing as an outpatient procedure: a comparison of overall cost and review of safety

Abstract

Recent advancements in arthroplasty surgical techniques and perioperative protocols have reduced the duration of hospitalization and length of recovery, allowing surgeons to perform joint replacement as an outpatient procedure. This study aims to evaluate the cost-effectiveness and safety of outpatient hip resurfacing. Two experienced surgeons performed 485 resurfacing surgeries. We retrospectively compared clinical outcomes and patient satisfaction with published outpatient total hip results. Furthermore, we compared average insurance reimbursement with that of local inpatient hip replacement. No major complications occurred within 6 weeks. Of the 39 patients with previous inpatient experience, 37 (95%) believed their outpatient experience was superior. The average reimbursement for hip arthroplasty at local hospitals was $50,000, while the average payment for outpatient resurfacing at our surgery center was $26,000. We conclude that outpatient hip resurfacing can be accomplished safely, with high patient satisfaction, and at a tremendous financial savings to the insurer/patient.

Level of evidence

III

Electronic supplementary material

The online version of this article (10.1007/s12306-020-00637-z) contains supplementary material, which is available to authorized users.

Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty: VERITAS, a Randomized Controlled Trial

BACKGROUND

Financial burden for patients, providers, and payers can reduce access to physical therapy (PT) after total knee arthroplasty (TKA). The purpose of the present study was to examine the effect of a virtual PT program on health-care costs and clinical outcomes as compared with traditional care after TKA.

METHODS

At least 10 days before unilateral TKA, patients from 4 clinical sites were enrolled and randomized 1:1 to the virtual PT program (involving an avatar [digitally simulated] coach, in-home 3-dimensional biometrics, and telerehabilitation with remote clinician oversight by a physical therapist) or to traditional PT care in the home or outpatient clinic. The primary outcome was total health-care costs for the 12-week post-hospital period. Secondary (noninferiority) outcomes included 6 and 12-week Knee injury and Osteoarthritis Outcome Score (KOOS); 6-week knee extension, knee flexion, and gait speed; and 12-week safety measures (patient-reported falls, pain, and hospital readmissions). All outcomes were analyzed on a modified intent-to-treat basis.

RESULTS

Of 306 patients (mean age, 65 years; 62.5% women) who were randomized from November 2016 to November 2017, 290 had TKA and 287 (including 143 in the virtual PT group and 144 in the usual care group) completed the trial. Virtual PT had lower costs at 12 weeks after discharge than usual care (median, $1,050 compared with $2,805; p < 0.001). Mean costs were $2,745 lower for virtual PT patients. Virtual PT patients had fewer rehospitalizations than the usual care group (12 compared with 30; p = 0.007). Virtual PT was noninferior to usual PT in terms of the KOOS at 6 weeks (difference, 0.77; 90% confidence interval [CI], -1.68 to 3.23) and 12 weeks (difference, -2.33; 90% CI, -4.98 to 0.31). Virtual PT was also noninferior to usual care at 6 weeks in terms of knee extension, knee flexion, and gait speed and at 12 weeks in terms of pain and hospital readmissions. Falls were reported by 19.4% of virtual PT patients and 14.6% of usual care patients (difference, 4.83%; 90% CI, -2.60 to 12.25).

CONCLUSIONS

Relative to traditional home or clinic PT, virtual PT with telerehabilitation for skilled clinical oversight significantly lowered 3-month health-care costs after TKA while providing similar effectiveness. These findings have important implications for patients, health systems, and payers. Virtual PT with clinical oversight should be considered for patients managed with TKA.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Increasing body mass index and abdominal subcutaneous fat thickness are associated with increased skin-to-epidural space distance in pregnant women

BACKGROUND

Body mass index does not indicate the distribution of adipose tissue. Central adiposity may be measured using ultrasound measurement of subcutaneous fat thickness. This study determined if the abdominal subcutaneous fat thickness measured correlated with skin-to-epidural space distance at delivery, and compared this with the booking body mass index.

METHODS

We analysed a sub-set of participants from a single-centre, prospective cohort study that assessed the relationship between subcutaneous fat thickness and maternity outcomes. Abdominal subcutaneous fat thickness measurements were obtained during the routine fetal anomaly scan. The skin-to-epidural space distance was obtained in those having epidural or combined spinal-epidural analgesia. Linear regression was used to test for strength of association and adjusted R² values calculated to determine if subcutaneous fat thickness or body mass index was more strongly associated with skin-to-epidural space distance.

RESULTS

The 463 women had a median (IQR) booking body mass index of 25.0 kg/m² (21.8-29.3) and subcutaneous fat thickness of 16.2 mm (13.0-21.0). The median (IQR) skin-to-epidural space distance was 5.0 cm (4.5-6.0). Both parameters significantly correlated with skin-to-epidural space distance (r=0.53 and 0.68 respectively, P <0.001). Adjusted linear regression coefficient (95% CI) for subcutaneous fat thickness was 0.09 (0.08 to 0.11), R²=0.30 and for body mass index 0.12 (0.11 to 0.13), R²=0.47.

CONCLUSIONS

Booking body mass index had a stronger relationship with skin-to- epidural space distance at delivery than subcutaneous fat thickness, explaining 47% of the variation in the skin-to-epidural distance.

Epidural extension failure in obese women is comparable to that of non-obese women

BACKGROUND

Management of labor epidurals in obese women is difficult and extension to surgical anesthesia is not always successful. Our previous retrospective pilot study found epidural extension was more likely to fail in obese women. This study used a prospective cohort to compare the failure rate of epidural extension in obese and non-obese women and to identify risk factors for extension failure.

METHODS

One hundred obese participants (Group O, body mass index ≥ 40 kg/m² ) were prospectively identified and allocated two sequential controls (Group C, body mass index ≤ 30 kg/m² ). All subjects utilized epidural labor analgesia and subsequently required anesthesia for cesarean section. The primary outcome measure was failure of the labor epidural to be used as the primary anesthetic technique. Risk factors for extension failure were identified using Chi-squared and logistic regression.

RESULTS

The odds ratio (OR) of extension failure was 1.69 in Group O (20% vs. 13%; 95% CI: 0.88-3.21, P = 0.11). Risk factors for failure in obese women included ineffective labor analgesia requiring anesthesiologist intervention, (OR 3.94, 95% CI: 1.16-13.45, P = 0.028) and BMI > 50 kg/m² (OR 3.42, 95% CI: 1.07-10.96, P = 0.038).

CONCLUSION

The failure rate of epidural extension did not differ significantly between the groups. Further research is needed to determine the influence of body mass index > 50 kg/m² on epidural extension for cesarean section.

Abstract 3: Association of Video- vs. Text-Based Informed Consent With Multicenter Registry Enrollment

Background: Low patient participation in clinical research undermines the generalizability of findings. Conducting informed consent by video rather than a traditional text format may enhance the appeal of research and break down barriers to participation.

Methods: The Patient and Provider Assessment of Lipid Management (PALM) Registry enrolled patients at U.S. cardiology, endocrinology, and primary care clinics to evaluate cholesterol management practices. PALM investigators developed an iPad-based video informed consent tool that included video segments totaling 8 minutes which patients navigated though a “game-ified” interface. At sites whose IRB did not approve the video tool, participants read a 6-page text consent form on the iPad. Characteristics of sites and site activation times were compared between sites that did and did not use the video consent tool using Pearson’s chi-square test for categorical variables and Wilcoxon’s signed rank test for continuous variables.

Results: Of 140 sites that enrolled 7904 patients in PALM, 60 (42.9%) used the video informed consent tool. Compared with sites using text consent, sites using the video consent tool were more often rural (16.7 vs. 3.8%, p = 0.01) and used a central IRB (91.7 vs. 80.0%, p = 0.06). Sites using video consent enrolled a greater proportion of patients who were ≥ 75 years old (27.5 vs. 23.6%, p < 0.001) or non-white (17.7 vs. 14.2%, p < 0.001). Sites using video consent had shorter times from site approach to first patient enrollment ( Figure ). Median (IQR) enrollment was 33 (12, 98) patients at sites using video consent versus 24 (12, 86) at sites using text consent only (p = 0.54); there was also no significant difference in median weekly enrollment rate (2.9 [1.1, 7.5] vs. 2.8 [1.3, 6.6], p = 0.73).

Conclusions: In this early experience with video consent in a multicenter registry, availability of video informed consent was associated with greater enrollment of older and non-white patients, faster speed to first patient enrolled, and numerically but not significantly more rapid enrollment compared with text informed consent.

Hyponatraemia and Moduretic-Grand Mal Seizures: A Review

Three cases are presented which emphasize the importance of hyponatraemia as a cause of grand mal seizures. The combination of hydrochlorothiazide and amiloride appears to increase the risk of hyponatraemia. We discuss the aetiology and treatment of hyponatraemia and review the necessity for such combination therapy. We recommend caution in prescribing diuretics and preparations such as Moduretic should be used only in those few patients shown to need potassium supplementation.

Abstract 247: A Randomized Controlled Study of a Platform to Maximize Patient Knowledge of Health Goals After Acute Myocardial Infarction

Objectives: Patients vary in the degree to which they understand and engage in their health care. We hypothesized that a personalized patient health education tool will promote patient communication and align patient and provider treatment goals in follow-up visits in order to optimize guideline adherence, including evidence-based therapy use and cardiovascular risk factor control, after an acute myocardial infarction (AMI).

Methods: We developed a personalized patient education tool that summarized each patient’s status at discharge of secondary prevention risk factors (blood pressure (BP), low density lipoprotein cholesterol (LDL-C) and glycemic control), medication use (aspirin, beta blocker, ACE inhibitor/ARB, statin, P2Y 12 inhibitor), and outpatient treatment goals. Patients were randomized 1:1 to usual care vs. receipt of the education tool within 2 weeks post-discharge (before the outpatient visit). We compared secondary prevention medication use, cardiovascular risk factor control, and awareness of treatment goals between randomized groups at 6 months post-discharge.

Results: Among 192 enrolled AMI patients, the median age was 60 years, 42% female, and 35% African American; demographic and clinical characteristics were well balanced between randomized groups. We noted high rates of secondary prevention therapy use at 6 months (Table). By 6 months post-discharge, mean systolic BP decreased by 10 mmHg with 80% of patients <140/90 mmHg, and mean LDL-C decreased by 13 mg/dl with 64% of patients under 100mg/dl. Overall, 36% of patients participated in cardiac rehabilitation. We observed no significant differences between randomized groups in any of these outcomes. Only 9% of patients who received the education tool brought it to their outpatient visit for discussion.

Conclusion: Though secondary prevention medication use remains reasonably high at 6 months, achievement of secondary prevention health goals remains suboptimal after a myocardial infarction. Few patients utilized the health tool in discussions with outpatient providers during their follow-up visit which likely explains the lack of outcomes differences between randomized groups. Further work is needed to find effective interventions to engage patients and promote sustained behavioral modification for secondary prevention.

Training Teachers in Human Sexuality: Effect on Attitude and Knowledge

The current study investigated the extent to which a 9-wk. course on human sexuality for teachers changed their knowledge and attitudes. Significant changes were found from the pre- to post-course assessment on both measures of knowledge. The only significant change in attitude scores, however, was on the Autoeroticism Attitude Scale. This pilot program encourages further exploration of the differences in methodological approaches and the long-term effects of training on specific attitudes and knowledge.

Risks and Benefits Associated With Prestroke Antiplatelet Therapy Among Patients With Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator

IMPORTANCE

Intravenous tissue plasminogen activator (tPA) is known to improve outcomes in ischemic stroke; however, many patients may have been receiving antiplatelet therapy before acute ischemic stroke and could face an increased risk for bleeding when treated with tPA.

OBJECTIVE

To assess the risks and benefits associated with prestroke antiplatelet therapy among patients with ischemic stroke who receive intravenous tPA.

DESIGN, SETTING, AND PARTICIPANTS

This observational study used data from the American Heart Association and American Stroke Association Get With the Guidelines-Stroke registry, which included 85 072 adult patients with ischemic stroke who received intravenous tPA in 1545 registry hospitals from January 1, 2009, through March 31, 2015. Data were analyzed during the same period.

EXPOSURES

Prestroke antiplatelet therapy before tPA administration for acute ischemic stroke.

MAIN OUTCOMES AND MEASURES

Symptomatic intracranial hemorrhage (sICH), in-hospital mortality, discharge ambulatory status, and modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]).

RESULTS

Of the 85 072 registry patients, 38 844 (45.7%) were receiving antiplatelet therapy before admission; 46 228 patients (54.3%) were not. Patients receiving antiplatelet therapy were older (median [25th-75th percentile] age, 76 [65-84] vs 68 [56-80] years) and had a higher prevalence of cardiovascular risk factors. The unadjusted rate of sICH was higher in patients receiving antiplatelet therapy (5.0% vs 3.7%). After risk adjustment, prior use of antiplatelet agents remained associated with higher odds of sICH compared with no use (adjusted odds ratio [AOR], 1.18 [95% CI, 1.10-1.28]; absolute difference, +0.68% [95% CI, 0.36%-1.01%]; number needed to harm [NNH], 147). Among patients enrolled on October 1, 2012, or later, the highest odds (95% CIs) of sICH were found in 15 116 patients receiving aspirin alone (AOR, 1.19 [1.06- 1.34]; absolute difference [95% CI], +0.68% [0.21%-1.20%]; NNH, 147) and 2397 patients receiving dual antiplatelet treatment of aspirin and clopidogrel (AOR, 1.47 [1.16-1.86]; absolute difference, +1.67% [0.58%-3.00%]; NNH, 60). The risk for in-hospital mortality was similar between those who were and were not receiving antiplatelet therapy after adjustment (8.0% vs 6.6%; AOR, 1.00 [0.94-1.06]; nonsignificant absolute difference, -0.01% [-0.37% to 0.36%]). However, patients receiving antiplatelet therapy had a greater risk-adjusted likelihood of independent ambulation (42.1% vs 46.6%; AOR, 1.13 [1.08-1.17]; absolute difference, +2.23% [1.55%-2.92%]; number needed to treat, 43) and better functional outcomes (modified Rankin Scale score, 0-1) at discharge (24.1% vs 27.8%; AOR, 1.14; 1.07-1.22; absolute difference, +1.99% [0.78%-3.22%]; number needed to treat, 50).

CONCLUSIONS AND RELEVANCE

Among patients with an acute ischemic stroke treated with intravenous tPA, those receiving antiplatelet therapy before the stroke had a higher risk for sICH but better functional outcomes than those who were not receiving antiplatelet therapy.

Gastric duplication cyst masquerading as a mucinous pancreatic cyst: case report and literature review

Gastric duplication cysts are rare cystic neoplasms that are often difficult to distinguish from other entities. We describe a healthy 44-year-old woman who presented with acute right lower quadrant abdominal and flank pain as well as chronic nausea and constipation. Her physical examination was unremarkable but contrasted computed tomography revealed a 6 cm cystic lesion between the stomach and body of the pancreas. Endoscopic ultrasonography and fluid analysis were consistent with a mucinous cyst with a markedly elevated fluid carcinoembryonic antigen level. The patient subsequently underwent a laparoscopic distal pancreatectomy, which was converted to an open procedure when the lesion was noted to be adherent to the coeliac axis. Intraoperative endoscopy revealed no abnormality. Final pathology revealed a gastric duplication cyst. The patient recovered well and was asymptomatic on follow-up. In this report, we discuss the incidence, natural history and management of this rare entity.

Tools for the job: why relying on risk assessment tools is still a risky business

This theoretical review paper examines the applicability of assessment tools, guidelines and protocols in mental health and substance use care on the basis of the construction of such tools and their reliance on aggregate and actuarial methodologies. Evidence-based practice leads clinicians to increasing reliance on tools for assessment of health status, risk and prediction for a range of clinical needs for individual clients. In the longer-term management of people with enduring and chronic mental health and substance misuse problems, clinicians are often dealing with complex and unstable health needs. The tools available, however, are developed on the basis of majority population evidence and on presumptions of similarity and stability over time. This paper provides explanation of the basis for the development of such tools and argues that clinicians need to be able to evaluate the applicability of tools used for their clients and not just evaluate the internal validity of the tools used to make individual and contextual decisions about individual clients.

Effectiveness of pedometer use in motivating active duty and other military healthcare beneficiaries to walk more

Although implementing a regular exercise program may initially seem overwhelming to individuals attempting weight loss, increasing walking with a focus on steps-per-day may be a more realistic means for encouraging physical activity. This study evaluated the effectiveness of pedometer use for motivating an increase in physical activity among overweight/obese military beneficiaries. Participants (N=106) were randomly assigned to either the "Usual Lifestyle" (no change in activity advised) or "Pedometer" group (education and encouraged to obtain 10,000 steps per day), and both groups were assessed for changes in physical activity, anthropometric measures, and clinic measures over time. Results (n=89) demonstrated improvements in physical activity and all measured indices across both groups. There was a statistically significant increase in steps per day by time (P<.001), however, no statistically significant difference between treatment groups over time (P=.167). Approximately 49.4% of participants achieved the 10,000 steps per day goal at follow-up. All secondary measured indices, except blood pressure, demonstrated a significant change overall from baseline to posttest: weight (P<.001), BMI (P<.001), percent body fat (P=.001) and heart rate (P=.005). Findings indicate that all participants made lifestyle changes, possibly as a result of frequent investigator-participant interaction, however, more likely due to the pedometer serving as a tangible tool to constantly remind the wearer to get up and walk more, regardless if a step count is tracked.

Field-scale dispersal of Aphodius dung beetles (Coleoptera: Scarabaeidae) in response to avermectin treatments on pastured cattle

Very few studies have examined, at the field scale, the potential for faecal residues in the dung of avermectin-treated cattle to affect dung-breeding insects. The current study examined populations of dung beetles (Scarabaeidae: Aphodius) using pitfall traps baited with dung from untreated cattle on 26 fields across eight farms in southwest Scotland. The fields were grazed either by untreated cattle or by cattle treated with an avermectin product, i.e. doramectin or ivermectin. During the two-year study, significantly more beetles were trapped in fields grazed by treated cattle (n=9377 beetles) than in fields where cattle remained untreated (n=2483 beetles). Additional trials showed that beetles preferentially colonised dung of untreated versus doramectin-treated cattle. This may explain the higher captures of beetles in traps baited with dung of untreated cattle, which were located in fields of treated cattle. Given that Aphodius beetles avoided dung of treated cattle in the current study, the potential harmful effects of avermectin residues in cattle dung could be reduced through livestock management practices that maximise the availability of dung from untreated livestock in areas where avermectins are being used.

Characteristics of internet child pornography offenders: a comparison with child molesters

The aim of this exploratory study was to compare internet sex offenders with a matched group of child molesters in the Greater London Area. Over an 8-month period 210 subjects were assessed, of whom 90 were internet sex offenders and 120 were child molesters. A wide range of background data was collected, including a number of psychometric measures to determine risk and personality traits. The research identified a number of similarities between internet sex offenders and child molesters on background variables. Specifically, in comparison to the child molesters, the internet offenders reported more psychological difficulties in adulthood and fewer prior sexual convictions. The socio-affective characteristics of internet offenders and child molesters look similar, but the antisocial variables, such as, 'acting out' and breaking social rules underlines their difference. The follow up research was carried out after a short period of time at risk-averaging 18 months-but suggested that internet sex offenders were significantly less likely to fail in the community than child molesters in terms of all types of recidivism.

Effects of avermectin residues in cattle dung on yellow dung fly Scathophaga stercoraria (Diptera: Scathophagidae) populations in grazed pastures

The effects of avermectin exposure on natural populations of the yellow dung fly, Scathophaga stercoraria Linnaeus, were investigated at the field scale on farms in south-west Scotland. Pastures forming the focus of the study were grazed with either untreated cattle or cattle receiving standard, manufacturer-recommended treatment regimes of an avermectin product. Flies were sampled between April and July in 2002 and 2003 using dung-baited pitfall traps. Abundance and wing asymmetry in S. stercoraria populations were examined in relation to a range of environmental and management variables (including avermectin exposure, pasture management intensity, weather and season). Data used for abundance analyses were collected in fields where treated cattle had been dosed with either doramectin or ivermectin, while the data for the asymmetry analyses were from a subset of fields where treated cattle had been dosed with doramectin only. While abundance of S. stercoraria varied significantly between years and with season, there was no difference in their abundance between fields grazed by avermectin-treated or untreated cattle. Asymmetry was significantly higher in fly populations in fields grazed by doramectin-treated cattle, suggesting that exposure to doramectin during development could have imposed some degree of environmental stress. While these results suggest that exposure to doramectin residues in dung on grazed pastures may have sublethal effects on the insects developing in that dung, there was no evident avermectin effect on the abundance of adult S. stercoraria occurring in the pastures.

Activity of rat UGT1A1 towards benzo[a]pyrene phenols and dihydrodiols

Four UDP-glucuronosyltransferases from the rat UGT1A family were tested for activity towards benzo[a]pyrene phenols and dihydrodiols. UGT1A1 and UGT1A7 were found to be broadly active towards BaP metabolites. Antisera recognizing rat UGT1A1 and UGT1A7 were used to assess UGT levels in relation to UGT activity towards benzo[a]pyrene-7,8-dihydrodiol (BPD). The rank BPD UGT activities were liver=intestine≫kidney, whereas UGT1A1 was highest in liver and UGT1A7 was highest in intestine. Phenobarbital, an inducer of hepatic UGT1A1, only slightly increased BPD UGT activity, whereas UGT1A7 inducers more potently increased the activity. Inhibition studies using the differential UGT1A1 inhibitor, bilirubin, suggest that UGT1A1 is not a major contributor to the constitutive BPD glucuronidating activity of control rat liver microsomes. These data suggest that multiple UGT1A enzymes contribute to glucuronidation of BPD and other BaP metabolites, and that their relative contributions depend on tissue- and environmental-specific factors.

Effect of uncertainty on the time course for selection of verbal name codes

Response selection takes time. Hick's law (Hick, 1952) predicts that the time course of response selection is a logarithmic function of the number of equally likely response alternatives. However, recent work has shown that oculomotor responses constitute noteworthy exceptions in that the latencies of saccades (Kveraga, Boucher, & Hughes, 2002) and smooth pursuit movements (Berryhill, Kveraga, Boucher, & Hughes, 2004) are completely independent of response uncertainty. This finding extends to the case in which the required response was known in advance (i.e., simple reaction times [RTs] were equivalent to choice RTs). In view of these results, we reevaluated reports that latencies to name visually presented digits (Experiment 1) and/or repeat aurally presented digits (Experiment 2) are similarly independent of the size of the response set. We found that naming latencies were equivalent for response set sizes from one to eight, but simple RTs (response set of one) were faster. Thus, the overlearned task of digit naming is indeed highly automatic but has not reached the level of automaticity characteristic of the oculomotor system.

Nurse staffing levels and budgeted expenditure in acute mental health wards: a benchmarking study

This paper describes benchmarking research undertaken within one former National Health Service Executive region examining acute ward funded and actual staffing establishments and funded expenditure for mental health nursing staff. Staffing establishment data were obtained for all 73 acute wards within the region. Of the established posts for trained mental health nurses across these wards, it was identified that there were 12% vacancies (117.99 whole time equivalent) at the time of the study. While some of the shortfall was dealt with by recruiting untrained nursing staff above funded establishments, there remained an overall shortfall in the total nursing workforce across the system of acute wards in the region. Although most of the provider trusts in the region were in development or experiencing major organizational change at the time of the study, considerable variation existed within and between trusts. Variations were identified in funded and actual nursing establishments and cost per bed, raising significant issues for trusts and their local mental health economies. Variations based on mixed- and single-sex wards were also noted. Findings are discussed in respect of the issues raised for the development of wards, provider trusts and their local systems. The utility of the methodology developed in this work is also discussed.