Effects of a peer health coaching program on college student lifestyle behaviors

Objective: Health coaching (HC) may promote healthy behaviors in incoming college students. Participants: 187 undergraduate students (76% female; age 18.6 ± 1.6) were recruited to participate in a peer HC program. Methods: Participants received four HC sessions in eight-weeks to work toward self-selected goals of physical activity (PA), diet, or stress management. PA was assessed using the International Physical Activity Questionnaire Short-Form, diet with the Eating Habits Confidence Survey, and stress with the Perceived Stress Scale. Results: Repeated measures ANOVAs investigated lifestyle behavior changes in 130 participants. Significant effects of time were reported, with a 39.6% gain in PA, 9.9% increase in dietary habit, and 16.3% decline in stress levels with moderate to large effect sizes (ηp2: 0.07-0.17; p< 0.01). Conclusion: The peer HC model promoted healthy lifestyles in college students. Additional research is needed to understand the effects of HC specifically for each goal, and student reactions to peer-led HC.

Long-term outcomes among a cohort of 4296 implantable cardioverter-defibrillator patients: insights from the UMBRELLA study

Background

Large observational real-world studies describing modern implantable cardioverter-defibrillator (ICD) populations with long-term follow-up are lacking.

Purpose

To assess the incidence of arrhythmias in a cohort of contemporary patients undergoing ICD implant from 2005 and 2017 and to analyze the arrhythmic risk and mortality according to their clinical profiles.

Methods

UMBRELLA (NTC01561144) is a prospective, multicentre, nationwide study of ICD patients followed by remote monitoring. All device information was automatically stored through the remote monitoring system and a blinded review of all the stored arrhythmic episodes was performed. The study outcomes were first appropriate ICD therapy and all-cause death.

Results

The study population consisted of 4296 patients (61.9±12.9 years, ischaemic cardiomyopathy (ICM): n=2150, dilated cardiomyopathy (DCM): n=1166, valvular heart disease (VHD): n=119, hypertrophic cardiomyopathy (HCM): n=294, arrhythmogenic right ventricular cardiomyopathy (ARVC): n=71, Brugada syndrome (BS): n=143, long QT syndrome (LQTS): n=43, and adult congenital heart disease (ACHD): n=60)). Primary prevention (PP) was the main indication (n=2758).

During a mean follow-up of 46.6±27.3 months, 16,067 episodes of sustained ventricular arrhythmia (SVA) occurred in 1344 patients. Appropriate ICD therapy was delivered to 85.7% (n=13,767) episodes of SVA in 1173 patients (27.3% of population). A higher risk of first appropriate ICD therapy was observed in VHD (HR: 1.94, 95% CI: 1.43–2.62), ARVC (HR: 1.84, 95% CI: 1.28–2.66), ICM (HR: 1.51, 95% CI: 1.29–1.78), and DCM (HR: 1.28, 95% CI: 1.07–1.53) whereas patients with HCM (HR: 0.72, 95% CI: 0.54–0.96) and BS (HR: 0.25, 95% CI: 0.14–0.45) were at significantly lower risk (Figure 1A). In multivariate analysis (Table 1), age, gender, atrial fibrillation (AF), secondary prevention, LVEF ≤35%, and QRS width emerged as clinical predictors of appropriate ICD therapy, whereas CRT-D correlated with lower risk. An independently higher risk was found in DCM, VHD, and ARVC, and a lower risk in BS patients.

At follow-up, 590 deaths (13.4% of population) were reported. Patients with ICM (HR 3.90, 95% CI: 2.58–5.90), DCM (HR 3.33, CI 95%: 2.18–5.10), and VHD (HR 3.97, CI 95%: 2.25–6.99) had worse prognoses and it was significantly better in BS patients (HR 0.11, 95% CI: 0.01–0.67, p=0.017) (Figure 1B). In multivariate analysis, age, gender, AF, renal failure, diabetes and reduced LVEF, emerged as independent predictors of all-cause death (Table 1).

Conclusions

Irrespective of the aetiology, contemporary ICD patients with an arrhythmic substrate derived from left ventricular systolic dysfunction had a similar risk of ICD life-saving interventions and death.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Q Fever in Southern California: a Case Series of 20 Patients from a VA Medical Center

Query fever (Q fever), caused by Coxiella burnetii, was first described in southern California in 1947. It was found to be endemic and enzoonotic to the region and associated with exposure to livestock. We describe a series of 20 patients diagnosed with Q fever at a Veterans Affairs hospital in southern California, with the aim of contributing toward the understanding of Q fever in this region. Demographics, laboratory data, diagnostic imaging, risk factors, and treatment regimens were collected via a retrospective chart review of patients diagnosed with Q fever at our institution between 2000 and 2016. Cases were categorized as acute or chronic and confirmed or probable. The majority presented with an acute febrile illness (90%). There was a delay in ordering diagnostic serology from the time of symptom onset (acute cases, average 31.9 days; chronic cases, average 63 days), and 15% progressed from acute to chronic infection. Of the chronic cases, 22.2% had endocarditis, 22.2% had endovascular infection, and 11.1% had both endocarditis and endovascular infection. The geographic distribution revealed that 20% resided in rural areas. Of the cases of Q fever that died, death attributed to Q fever was associated with an average diagnostic delay of 65.5 days. Acute Q fever is underreported in this region largely because of its often nonspecific clinical presentation.

P5425Prognostic value of NYHA functional class in heart failure patients undergoing primary prevention implantable cardioverter defibrillator therapy

Background

NYHA functional class (FC) is used for selection of heart failure (HF) patients who are candidates to primary prevention (PP) implantable cardioverter defibrillator (ICD) therapy. However, FC is subjectively estimated and concerns about its real prognostic value are still present in this setting.

Purpose

To compare whether mortality and arrhythmic risk are different, in a cohort of HF patients undergoing PP ICD-only implant, according to their FC.

Methods

All HF patients with left ventricle ejection fraction (LVEF) ≤35%, undergoing first prophylactic ICD-only implant were collected from the UMBRELLA nationwide registry (2006–2015). The sample was divided into three groups: no symptoms (NYHA I), mildly symptomatic patients (NYHA II) and severely symptomatic (NYHA III) patients. Outcomes were studied as follow: all-cause death, cardiovascular mortality and arrhythmia free survival (surrogate marker of sudden cardiac death) defined as survival free of first appropriate ICD therapy delivered in ventricular fibrillation (VF) window. Arrhythmic events were collected by remote monitoring and reviewed by a committee of experts.

Results

Six hundred and twenty one patients were identified (61.1±11.4 years, 87.3% male). Distribution of study groups was as follow: 101 patients in NYHA I; 411 in NYHA II; and 109 in NYHA III. More symptomatic patients were older and had higher prevalence of atrial fibrillation (AF) and chronic kidney disease (CKD). Higher rates of optimal medical treatment were present among study groups (beta-blockers: 92.1%; ACEI or ARB: 86.8%; aldosterone antagonists: 60.2%). After a median follow-up of 4.2 years (IQR, 2.7–5.7 years) 126 patients died (event rate: 20.3%). All-cause mortality was higher in patients with worse FC (13.9% vs. 18.3% vs. 32.9% for NYHA I, II and III respectively; p<0.001, log-rank test). Seventy-eight out of 126 deaths were related to cardiovascular causes (overall event rate: 12.6%). Cardiovascular mortality risk was also higher in more symptomatic patients (6.9% vs. 11% vs. 23.9% for NYHA I, II and III respectively; p<0.001, log-rank test). One hundred and seventeen patients received afirst appropriate ICD therapy (19.4%). Arrhythmia free survival was not different among study groups (20.8% vs. 18.7% vs. 20.8% for NYHA I, II and III, respectively; p=0.495, log-rank test). Cumulative incidence curves for the three outcomes are shown in Figure 1. After multivariate analysis, worse NYHA class independently predicted cardiovascular mortality but not all-cause death. Moreover, diabetes, AF and CKD strongly predicted both all-cause and cardiovascular mortality.

Figure 1

Conclusions

In HF patients, prophylactic ICD seems to be useful in preventing death due to life threatening arrhythmias, regardless of the baseline FC. Nevertheless, the combination of NYHA class with other comorbidities may be useful to select those ICD candidates who obtain less survival benefit.

Clinician judgment vs formal scales for predicting intracerebral hemorrhage outcomes

OBJECTIVE

To compare the performance of formal prognostic instruments vs subjective clinical judgment with regards to predicting functional outcome in patients with spontaneous intracerebral hemorrhage (ICH).

METHODS

This prospective observational study enrolled 121 ICH patients hospitalized at 5 US tertiary care centers. Within 24 hours of each patient's admission to the hospital, one physician and one nurse on each patient's clinical team were each asked to predict the patient's modified Rankin Scale (mRS) score at 3 months and to indicate whether he or she would recommend comfort measures. The admission ICH score and FUNC score, 2 prognostic scales selected for their common use in neurologic practice, were calculated for each patient. Spearman rank correlation coefficients (r) with respect to patients' actual 3-month mRS for the physician and nursing predictions were compared against the same correlation coefficients for the ICH score and FUNC score.

RESULTS

The absolute value of the correlation coefficient for physician predictions with respect to actual outcome (0.75) was higher than that of either the ICH score (0.62, p = 0.057) or the FUNC score (0.56, p = 0.01). The nursing predictions of outcome (r = 0.72) also trended towards an accuracy advantage over the ICH score (p = 0.09) and FUNC score (p = 0.03). In an analysis that excluded patients for whom comfort care was recommended, the 65 available attending physician predictions retained greater accuracy (r = 0.73) than either the ICH score (r = 0.50, p = 0.02) or the FUNC score (r = 0.42, p = 0.004).

CONCLUSIONS

Early subjective clinical judgment of physicians correlates more closely with 3-month outcome after ICH than prognostic scales.

Splenic abscesses in a returning traveler

Burkholderia, an aerobic gram-negative rod, is the causative organism behind melioidosis and is a common soil and water organism found predominantly in South-East Asia. We report the case of a 68 year-old man returning from an extended trip to the Philippines, with splenic hypodense lesions on abdominal computer tomography scan, later confirmed to be culture-positive for Burkholderia pseudomallei. The patient was treated with a course of intravenous ceftazidime followed by eradication therapy with oral doxycycline and trimethoprim-sulfamethoxazole. He recovered with complete resolution of symptoms at follow up. In a returning traveler from an endemic area, melioidosis should be considered as part of the differential for any febrile illness with abscesses.

Abstract 211: Subjective Judgments of Physicians and Nurses Are More Accurate Than Formal Clinical Scales in Predicting Functional Outcome After Intracerebral Hemorrhage

Introduction: Providing an accurate prognosis is a fundamental responsibility of care providers for patients with intracerebral hemorrhage (ICH). The ICH and FUNC Scores are common clinical scales designed to predict functional outcome and mortality for ICH patients.

Hypothesis: The ICH Score and FUNC Score have superior accuracy, compared to the early clinical judgment of physicians and nurses, with regards to the prediction of the Modified Rankin Scale (mRS) achieved by ICH patients at 3 months.

Methods: We conducted a prospective study at 5 centers. For each consecutive adult patient admitted with primary ICH, one physician and one nurse on the treatment team were asked for prediction of mRS at 3 months. All predictions were collected within 24 hours of admission. ICH and FUNC Scores on admission and blinded outcome at 3 months were obtained for each patient, in part using data collected for the ongoing Ethnic/Racial Variations with ICH (ERICH) project. Predictive ability was measured by Spearman’s rank correlation (r).

Results: For a total of 100 patients, 100 physicians (75 attendings, 25 trainees) and 100 nurses gave predictions. In order of strength of association with actual 3-month mRS, correlations were attending physicians r = 0.81, nurses r = 0.72, and trainees r = 0.66. Although suggestive, none of these groups were statistically superior (p > 0.10). However, nurses (p = 0.015) and attending physicians (p = 0.002), but not trainees (p = 0.57), were superior in their predictive ability over ICH Score (r = 0.55). Similarly, nurses (p = 0.0003) and attending physicians (p < 0.0001), but not trainees (p = 0.27), were superior over FUNC Score (r = -0.46). This accuracy advantage remained when examining predictions for (1) only those patients alive at 3 months (n = 65), and (2) only those patients for whom providers indicated that they would not recommend comfort care within the first 24 hours (n = 82).

Conclusions: The ICH Score and FUNC Score did not have superior accuracy, compared to subjective clinical judgment, with regards to prediction of 3-month ICH outcome.

Oxidation of cellular thiols by hydroxyethyldisulphide inhibits DNA double-strand-break rejoining in G6PD deficient mammalian cells

PURPOSE

We investigated the effect of protein- and non protein-thiol oxidation on DNA double-strand-break (DSB) rejoining after irradiation and its relevance in the survival of CHO cells.

MATERIALS AND METHODS

We used mutant cells null for glucose 6 phosphate dehydrogenase (G6PD) activity since reducing equivalents, required for reduction of oxidized thiols, are typically generated through G6PD regulated production of NADPH. Cellular thiols were oxidized by pre-incubating the cells with hydroxyethyldisulphide (HEDS), the oxidized form of mercaptoethanol (ME). The concentrations of the intracellular and extracellular non-protein thiols (NPSH), glutathione, cysteine and mercaptoethanol were quantitated by HPLC. Protein thiols (PSH) were estimated using Ellman's reagent. Cell survival was determined by clonogenic assay. The induction and rejoining of DSB in cells was quantitated by Pulse Field Gel Electrophoresis after exposure to ionizing radiation.

RESULTS

Much lower bioreduction of HEDS was found in the G6PD deficient mutants (E89) than in the wild-type cells (K1). A 1 h treatment of E89 cells with HEDS produced almost complete depletion of non-protein thiol (NPSH) and a 26% decrease in protein thiols. Only minor changes were found under similar conditions with K1 cells. When exposed to gamma radiation in the presence of HEDS, the G6PD null mutants exhibited a higher cell killing and decreased rate and extent of rejoining of DSB than were observed in K1 cells. Moreover, when the G6PD deficient cells were transfected with the gene encoding wild-type G6PD (A1A), they recovered close to wild-type cellular thiol status, cell survival and DSB rejoining.

CONCLUSIONS

These results suggest that a functioning oxidative pentose phosphate pathway is required for DSB rejoining in cells exposed to a mild thiol oxidant.

Glucose-6-phosphate dehydrogenase and the oxidative pentose phosphate cycle protect cells against apoptosis induced by low doses of ionizing radiation

The initial and rate-limiting enzyme of the oxidative pentose phosphate shunt, glucose-6-phosphate dehydrogenase (G6PD), is inhibited by NADPH and stimulated by NADP(+). Hence, under normal growth conditions, where NADPH levels exceed NADP(+) levels by as much as 100-fold, the activity of the pentose phosphate cycle is extremely low. However, during oxidant stress, pentose phosphate cycle activity can increase by as much as 200-fold over basal levels, to maintain the cytosolic reducing environment. G6PD-deficient (G6PD(-)) cell lines are sensitive to toxicity induced by chemical oxidants and ionizing radiation. Compared to wild-type CHO cells, enhanced sensitivity to ionizing radiation was observed for G6PD(-) cells exposed to single-dose or fractionated radiation. Fitting the single-dose radiation response data to the linear-quadratic model of radiation-induced cytotoxicity, we found that the G6PD(-) cells exhibited a significant enhancement in the alpha component of radiation-induced cell killing, while the values obtained for the beta component were similar in both the G6PD(-) and wild-type CHO cell lines. Here we report that the enhanced alpha component of radiation-induced cell killing is associated with a significant increase in the incidence of ionizing radiation-induced apoptosis in the G6PD(-) cells. These data suggest that G6PD and the oxidative pentose phosphate shunt protect cells from ionizing radiation-induced cell killing by limiting the incidence of radiation-induced apoptosis. The sensitivity to radiation-induced apoptosis was lost when the cDNA for wild-type G6PD was transfected into the G6PD(-) cell lines. Depleting GSH with l-BSO enhanced apoptosis of K1 cells while having no effect in the G6PD(-) cell line

Involvement of energy metabolism in the production of 'bystander effects' by radiation

These experiments were done to determine if interference with energy metabolism and REDOX biochemistry during low LET radiation exposure would alter the ability of medium harvested from the irradiated cells to induce a bystander effect in unirradiated cells. Human keratinocyte cells and CHO-K1 mutant cell lines were irradiated using cobalt 60. Clonogenic assays were used to determine the reproductive death of the cells exposed to direct irradiation or medium from irradiated cells. The persistence in progeny was also examined. Use of apoptosis inhibitors or medium from the LDH or G6PD null cell lines, reduced or prevented the bystander effect. Transfection with G6PD recovered the effect. Treatment with anti-oxidant substances, L-lactate and L-deprenyl prevented bystander factor associated cell kill. The lactate analogue, oxamate, was less effective. Data from experiments where media harvested from the different cell lines was exchanged suggest that signal production and cellular response may involve different mechanisms. The effects on exposed cells were transmitted to progeny which also showed excessive levels of cell death for several generations. The results suggest that energy/REDOX metabolism may be involved in the expression of a radiation induced bystander response. Given the aberrant energy metabolism in tumour cells, this may have implications for dose escalation in radiotherapy.

Time versus replication dependence of EMS-induced delayed mutation in Chinese hamster cells

We have previously observed in Chinese hamster cells that ethyl methane sulfonate (EMS) induces mutations which are distributed over at least 10-14 cell divisions following treatment. This delayed appearance of mutations could be explained by EMS-induced lesions which remain in DNA and have a probability that is significantly less than 1.0 of producing base mispairing errors during successive replication cycles (replication-dependent). Alternatively, delayed mutation may be a time-dependent process in which a slow acting or damage inducible error-prone repair process removes persistent DNA lesions and replaces them with an incorrect base during the course of 7-10 days of colony growth following EMS exposure. To address this question, the distribution of HGPRT delayed mutation events (fifth division or later) in cells plated immediately for exponential growth after EMS treatment was compared with the distribution in cells which remained under confluent growth conditions for 8 days and then were replated. Both the distribution and rate of accumulation of delayed mutations (mutations/cell division) were similar in the two culture conditions. In contrast, the frequency of early mutations (before the fifth division) in the confluent population was reduced more than 2-fold compared to dividing cells. A comparison of the frequency of EMS-induced DNA lesions in the two populations revealed that the density inhibited population contained one third the DNA lesions of the exponential population. These results argue against a time-dependent process since, if this mechanism applies, one would expect an increase in early mutant events and a decrease in delayed events in the confluent population. The results, however, are consistent with a replication model in which potential early mutant lesions are preferentially removed in the density inhibited culture during the 8 days of incubation while lesions producing late mutants are not removed.

EMS and UV-light-induced colony sectoring and delayed mutation in Chinese hamster cells

PURPOSE

To review studies of mutagen-induced colony sectoring which demonstrate that UV light and EMS produce delayed mutational events in Chinese hamster ovary cells.

METHODS AND RESULTS

Since the late 1940s, it has been known that the treatment of a single bacterial or yeast cell with mutagenic agents produces complete mutant colonies (pures) and colonies composed of both mutant and non-mutant cell types (mosaics) with various sectored patterns. A similar sectoring phenomenon has been observed in Chinese hamster ovary cells (CHO) using the DNA alkylating agent ethyl methane sulphonate (EMS) or ultraviolet light. However, unlike bacteria and yeast, a significant fraction of CHO mutant colonies contained sectors of less than 1/2; i.e. 1/4, 1/8 and 1/16 sectors, suggesting a delayed production of mutations. Using various colony-replating approaches, it was found that these mutagenic agents produced the ratio of mutant to wild-type cells expected for a delayed mutational process which produces mutant events for at least 12-14 cell divisions following treatment. This delayed mutation phenomenon was observed at both the glucose-6-phosphate dehydrogenase (G6PD) and hypoxanthine guanine phosphoribosyltransferase (HGPRT) loci. Various mutational mechanisms for the production of delayed mutations are discussed.

CONCLUSIONS

These studies suggest that mutagens such as UV light and EMS induce long-term alterations in mammalian cells that act to increase the 'apparent' spontaneous mutation frequency. This delayed mutational decrease in stability of the genome may explain the accumulation over time of the multiple genetic changes observed in malignant tumours.

UV-light induces delayed mutations in Chinese hamster cells

The possibility was examined that mutational events at the glucose 6-phosphate dehydrogenase locus can be delayed for significantly more than one or two cell divisions following treatment of Chinese hamster cells with UV light. To detect these later mutant events, the proportion of G6PD-mutant cells in a colony was obtained by replating cells from a single colony 5-7 days after UV irradiation and staining the resulting colonies for G6PD activity. Eight colonies out of a total of 1657 colonies from the treated population yielded G6PD-negative colonies upon replating, while no mutant clones were obtained from 947 colonies grown from untreated cells. One clone contained only mutant cells suggesting that the mutation occurred before the first cell division after irradiation. A second clone contained a 1:1 ratio of mutant to wild-type cells suggesting that the mutation occurred at the first cell division. The remaining six clones contained low numbers of mutant cells and the ratio of mutant to wild-type cells in these clones was in agreement with the theoretical ratios expected for mutations occurring at the fourth (1:13), sixth (1:63), seventh (1:127), eighth (1:255), ninth (1:511), and eleventh (1:2047) cell division after UV light exposure. G6PD-mutant cells deficient in staining activity were isolated from five clones and all have significant reductions in G6PD activity confirming the genetically stable character of these mutants. These results support the conclusion that UV light induces mutants for up to 11 cell generations after treatment of mammalian cells and suggest that mutagens can induce in mammalian DNA long-term alterations which act to increase the apparently spontaneous mutation frequency.

Speciation in the Artemia genus: mitochondrial DNA analysis of bisexual and parthenogenetic brine shrimps

From the cloned mitochondrial DNAs (mtDNAs) isolated from two bisexual species, one Mediterranean, Artemia salina, and one American, Artemia franciscana, and two parthenogenetic (diploid and tetraploid) strains of Artemia parthenogenetica collected in Spain, physical maps have been constructed and compared. They are extremely different among themselves, much more than the differences between Drosophila melanogaster and D. yakuba and in the same range of different mammalian species such as mouse/rat or man/cow. The nucleotide sequences of two regions of mtDNA encoding parts of the cytochrome c oxidase subunit I (COI) and cytochrome b (Cytb) genes have been determined in the two bisexual species and the two parthenogenetic strains. Comparisons of these sequences have revealed a high degree of divergence at the nucleotide level, averaging more than 15%, in agreement with the differences found in the physical maps. The majority of the nucleotide changes are silent and there is a strong bias toward transitions, with the C<==>T substitutions being highly predominant. The evolutionary distance between the two Artemia parthenogenetica is high and there is no clear relationship with any of the bisexual species, including the one present nowadays in Spain. Using a combination of molecular (mtDNA) and morphological markers it is possible to conclude that all of these Artemia isolates should be actually considered as belonging to different species, even the two Artemia parthenogenetica diploidica and tetraploidica.

Subtotal calcanectomy for chronic heel ulceration

Subtotal or partial calcanectomy is a well-documented procedure. Its application in both ambulatory and nonambulatory patients with chronic heel ulceration is proposed as a desirable alternative to amputation. The authors expand on the candidate spectrum and discuss history, indications, criteria, technique, and postoperative course in different patient populations.