Outcomes of asymptomatic common bile duct stones detected at intraoperative cholangiography

AIMS

The aim of this study was to investigate the outcome of common bile duct stones (CBDS) in asymptomatic patients at laparoscopic cholecystectomy (LC) and intra-operative cholangiogram (IOC).

METHODS

All patients undergoing LC and IOC at Te Whatu Ora - Health New Zealand Waikato between January 2017 and January 2022 were retrospectively reviewed. Electronic records were screened for asymptomatic CBDS. Exclusion criteria were hyperbilirubinaemia, gallstone pancreatitis, cholangitis and imaging-detected CBDS. IOC reports were reviewed to determine presence of CBDS. A second blinded review was undertaken by a radiologist. Outcomes were use of endoscopic retrograde pancreatography (ERCP), complications and readmission with retained CBDS.

RESULTS

Included were 1,297 patients undergoing LC and IOC. Of these, 150 (24.1%) patients had a positive IOC, of which 58 (38.7%) were asymptomatic. Attempted flushing of CBDS was employed in 49 cases, 10 successfully. Common duct exploration was successful in a further six out of seven cases. Of the remaining 42 patients, 18 were offered ERCP. Seven had no stone at endoscopy. Sixteen had imaging, revealing clear ducts in 14. The remaining two then had ERCP confirming choledocholithiasis. Eight patients were managed expectantly, of whom none required readmission with retained stones.

CONCLUSION

Rates of retained asymptomatic stones after positive IOC were low. Acknowledging risks associated with intervention and low rates of readmission with retained CBDS, an expectant approach could be more readily considered.

Antidepressant Exposure and DNA Methylation: Insights from a Methylome-Wide Association Study

Importance

Understanding antidepressant mechanisms could help design more effective and tolerated treatments.

Objective

Identify DNA methylation (DNAm) changes associated with antidepressant exposure.

Design

Case-control methylome-wide association studies (MWAS) of antidepressant exposure were performed from blood samples collected between 2006-2011 in Generation Scotland (GS). The summary statistics were tested for enrichment in specific tissues, gene ontologies and an independent MWAS in the Netherlands Study of Depression and Anxiety (NESDA). A methylation profile score (MPS) was derived and tested for its association with antidepressant exposure in eight independent cohorts, alongside prospective data from GS.

Setting

Cohorts; GS, NESDA, FTC, SHIP-Trend, FOR2107, LBC1936, MARS-UniDep, ALSPAC, E-Risk, and NTR.

Participants

Participants with DNAm data and self-report/prescription derived antidepressant exposure.

Main Outcomes and Measures

Whole-blood DNAm levels were assayed by the EPIC/450K Illumina array (9 studies, N exposed = 661, N unexposed = 9,575) alongside MBD-Seq in NESDA (N exposed = 398, N unexposed = 414). Antidepressant exposure was measured by self- report and/or antidepressant prescriptions.

Results

The self-report MWAS (N = 16,536, N exposed = 1,508, mean age = 48, 59% female) and the prescription-derived MWAS (N = 7,951, N exposed = 861, mean age = 47, 59% female), found hypermethylation at seven and four DNAm sites (p < 9.42x10 -8 ), respectively. The top locus was cg26277237 ( KANK1, p self-report = 9.3x10 -13 , p prescription = 6.1x10 -3 ). The self-report MWAS found a differentially methylated region, mapping to DGUOK-AS1 ( p adj = 5.0x10 -3 ) alongside significant enrichment for genes expressed in the amygdala, the "synaptic vesicle membrane" gene ontology and the top 1% of CpGs from the NESDA MWAS (OR = 1.39, p < 0.042). The MPS was associated with antidepressant exposure in meta-analysed data from external cohorts (N studies = 9, N = 10,236, N exposed = 661, f3 = 0.196, p < 1x10 -4 ).

Conclusions and Relevance

Antidepressant exposure is associated with changes in DNAm across different cohorts. Further investigation into these changes could inform on new targets for antidepressant treatments.

3 Key Points

Question: Is antidepressant exposure associated with differential whole blood DNA methylation?Findings: In this methylome-wide association study of 16,536 adults across Scotland, antidepressant exposure was significantly associated with hypermethylation at CpGs mapping to KANK1 and DGUOK-AS1. A methylation profile score trained on this sample was significantly associated with antidepressant exposure (pooled f3 [95%CI]=0.196 [0.105, 0.288], p < 1x10 -4 ) in a meta-analysis of external datasets. Meaning: Antidepressant exposure is associated with hypermethylation at KANK1 and DGUOK-AS1 , which have roles in mitochondrial metabolism and neurite outgrowth. If replicated in future studies, targeting these genes could inform the design of more effective and better tolerated treatments for depression.

Dose Escalation in Esophageal Cancer: Comparing Pre-Accrual and On-Trial Target Volume Delineation in the UK SCOPE2 Trial

PURPOSE/OBJECTIVE(S)

The ongoing UK SCOPE2 trial evaluates radiotherapy (RT) dose escalation and PET-guided systemic therapy in esophageal cancer, and has an accompanying RT trials quality assurance (RTTQA) program, evolved through the preceding SCOPE trials. We compare pre-accrual with on-trial individual case review (ICR) target volume delineation (TVD).

MATERIALS/METHODS

Prior to recruitment, centers were required to undertake TVD exercises using 3D/4D DICOM datasets with relevant clinical details and a RT planning guidance document (RPGD) provided. Contours were then compared against the RTTQA team-defined gold standard. Exceptions were those who had satisfied QA requirements for a previous esophageal RT trial (NeoSCOPE). For ICRs, prospective reviews (prior RT start, PRs) were undertaken for each center's first submission, plus high-dose cases submitted pending formal safety review. Additional PRs were undertaken at the RTTQA team's discretion. Timely retrospective reviews (within 2 weeks of RT start, TRR) were also undertaken for a random 10% sample. TVDs were assessed for compliance using predefined criteria and the RPGD. Resubmission was requested at reviewer's discretion, usually due to unacceptable variation (UV) from protocol. Clarification was sought before contour approval/resubmission request if appropriate. Review outcomes were then evaluated. PTV6000 was new to SCOPE2, along with a greater emphasis on use of 4DCT than in prior SCOPE trials.

RESULTS

A total of 85 pre-accrual cases from 33 UK centers were reviewed, of which 20 (24%) were resubmissions, and 50 (59%) were accepted. 99 TVD UVs were observed in 49 cases, most commonly in CTVB (42/99, 42%), which included editing for normal structures and elective lymph node regions, followed by ITV (4D cases only, 14/52, 27%) and PTV6000 (13/99, 13%). 121 ICRs from 31 UK centers were available for review. 87 (72%) were PRs and 34 (28%) TRRs. 43 (36%) completed the relevant SCOPE2 exercise. 19 (16%) were resubmissions, and 82 (68%) were accepted. 72 UVs were observed in 45 ICRs; again, most commonly in CTVB (34/72, 48%), PTV6000 (high dose arm only, 11/46, 24%) and ITV (4D only, 5/26, 19%). Of the 45 cases where a UV was recorded, 16 (36%) had completed the relevant SCOPE2 pre-accrual. Comparing area of UV on SCOPE2 pre-accrual cases and ICRs, 3 (19%) contours contained the same (2 = CTVB, 1 = PTV6000), 5 (31%) contained different and 8 (50%) had no UVs at pre-accrual. The rate of UV was significantly lower for ICR than for pre-accrual submissions (0.60 and 1.16 respectively, p = 0.001).

CONCLUSION

Significantly fewer UVs in ICR compared with pre-accrual supports a robust, educational RTTQA program through national collaboration and evolving trial series. CTVB, along with newer volumes of ITV and PTV6000, were recurring UV domains and should inform RPGD development and RTTQA for ongoing recruitment and future trials.

The critical role of the specialized social worker as part of ED/hospital-based elder mistreatment response teams

The emergency department and hospital provide a unique and important opportunity to identify elder mistreatment and offer intervention. To help manage these complex cases, multi-disciplinary response teams have been launched. In developing these teams, it quickly became clear that social workers play a critical role in responding to elder mistreatment. Their unique skillset allows them to establish close connections with community resources, collaborate with various hospital stakeholders, support patients/families/caregivers through challenging situations, navigate the legal and protective systems, and balance patient safety and quality of life in disposition decision-making. The role of the social worker on these multi-faceted teams includes conducting a comprehensive biopsychosocial assessment, helping to develop a safe discharge plan, and making appropriate referrals, among other responsibilities. Any institution considering developing a multi-disciplinary program should recognize the critical importance of social work.

Seeking Excellence in End of Life Care UK (SEECare UK): a UK multi-centred service evaluation

OBJECTIVE

To evaluate the care of patients dying in hospital without support from specialists in palliative care (SPC), better understand their needs and factors influencing their care.

METHODS

Prospective UK-wide service evaluation including all dying adult inpatients unknown to SPC, excluding those in emergency departments/intensive care units. Holistic needs were assessed through a standardised proforma.

RESULTS

88 hospitals, 284 patients. 93% had unmet holistic needs, including physical symptoms (75%) and psycho-socio-spiritual needs (86%). People were more likely to have unmet needs and require SPC intervention at a district general hospital (DGH) than a teaching hospital/cancer centre (unmet need 98.1% vs 91.2% p0.02; intervention 70.9% vs 50.8% p0.001) and when end-of-life care plans (EOLCP) were not used (unmet need 98.3% vs 90.3% p0.006; intervention 67.2% vs 53.3% p0.02). Multivariable analyses demonstrated the independent influence of teaching/cancer hospitals (adjusted OR (aOR)0.44 CI 0.26 to 0.73) and increased SPC medical staffing (aOR1.69 CI 1.04 to 2.79) on need for intervention, however, integrating the use of EOLCP reduced the impact of SPC medical staffing.

CONCLUSION

People dying in hospitals have significant and poorly identified unmet needs. Further evaluation is required to understand the relationships between patient, staff and service factors influencing this. The development, effective implementation and evaluation of structured individualised EOLCP should be a research funding priority.

Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review

BACKGROUND

The natural history of incidental common bile duct stones (CBDS) is poorly understood. Current evidence is conflicting, with several studies suggesting the majority may pass spontaneously. Despite this, guidelines recommend routine removal even if asymptomatic. This study aimed to systematically review the outcomes of expectant management for CBDS detected on operative cholangiography during cholecystectomy.

METHODS

MEDLINE, Embase and CINAHL databases were systematically searched. Participants were adult patients with CBDS identified by intraoperative cholangiography. Intervention was regarded as any perioperative effort to remove common bile duct stones, including endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic and open bile duct exploration. This was compared to observation. Outcomes of interest included rates of spontaneous stone passage, success of duct clearance and complications. Risk of bias was assessed using the ROBINS-I tool.

RESULTS

Eight studies were included. All studies were non-randomized, heterogeneous and at serious risk of bias. In patients observed after a positive IOC, 20.9% went on to have symptomatic retained stones. In patients directed to ERCP for positive IOC, persistent CBDS were found in 50.6%. Spontaneous passage was not associated with stone size. Meta-analysis is dominated by the results from one large database, which recommends intervention for incidental stones, despite low rates of persistent stones seen at postoperative ERCP.

CONCLUSIONS

Further evidence is required before a definitive recommendation on observation can be made. There is some evidence that asymptomatic stones may be safely observed. In clinical scenarios where the risks of biliary intervention are considered high, a conservative strategy could be more widely considered.

Spring and latch dynamics can act as control pathways in ultrafast systems

Ultrafast movements propelled by springs and released by latches are thought limited to energetic adjustments prior to movement, and seemingly cannot adjust once movement begins. Even so, across the tree of life, ultrafast organisms navigate dynamic environments and generate a range of movements, suggesting unrecognized capabilities for control. We develop a framework of control pathways leveraging the non-linear dynamics of spring-propelled, latch-released systems. We analytically model spring dynamics and develop reduced-parameter models of latch dynamics to quantify how they can be tuned internally or through changing external environments. Using Lagrangian mechanics, we test feedforward and feedback control implementation via spring and latch dynamics. We establish through empirically-informed modeling that ultrafast movement can be controllably varied during latch release and spring propulsion. A deeper understanding of the interconnection between multiple control pathways, and the tunability of each control pathway, in ultrafast biomechanical systems presented here has the potential to expand the capabilities of synthetic ultra-fast systems and provides a new framework to understand the behaviors of fast organisms subject to perturbations and environmental non-idealities.

Temperature-related chest pain presentations and future projections with climate change

Background

Climate change has led to increased interest in studying adverse health effects relating to ambient temperatures. It is unclear whether incident chest pain is associated with non-optimal temperatures and how chest pain presentation rates might be affected by climate change.

Methods

The study included ambulance data of chest pain presentations in Melbourne, Australia from 1/1/2015 to 30/6/2019 with linkage to hospital and emergency discharge diagnosis data. A time series quasi-Poisson regression with a distributed lag nonlinear model was fitted to assess the temperature-chest pain presentation associations, after adjusting for season, day of the week and long-term trend. Future excess chest pain presentations associated with cold and heat were projected under six general circulation models under medium and high emission scenarios.

Results

In 206,789 chest pain presentations, mean (SD) age was 61.2 (18.9) years and 50.3% were female. Significant heat- and cold-related increased risk of chest pain presentations were observed for mean air temperatures above and below 20.8°C, respectively (Figure 1). Excess chest pain presentations related to heat were observed in all subgroups, but appeared to be attenuated for older patients (≥70 years) and patients of higher socioeconomic status (SES). We projected no significant change in net temperature-related chest pain presentations with climate change under medium- and high-emission scenarios, with increases in heat-related chest pain presentations offset by decreases in chest pain presentations related to cold temperatures.

Conclusions

Heat- and cold-exposure appear to increase risk of chest pain presentations, especially among younger patients and patients of lower SES. In Melbourne, Australia, chest pain presentations overall were not projected to increase with climate change, but increases in heat-related chest pain presentations highlight the importance of risk mitigation strategies to minimise adverse health impacts on hotter days.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Alfred Health.

Impact of ambulance off-load delays on mortality in patients with chest pain

Background

Ambulance off-load delays in transferring patient care to emergency departments (EDs) are increasingly common, but it is unclear whether clinical outcomes are impacted.

Methods

Population-based cohort study of ambulance attendances for non-traumatic chest pain transported to ED in Victoria, Australia (1/1/2015–30/6/2019) excluding patients transported to hospital with “lights and sirens” or triaged as ED category 1. Multivariable models were used to assess the relationship between ambulance off-load times and 30-day mortality and ambulance re-attendance for chest pain.

Results

The study included 213,544 ambulance attendances for chest pain (mean age 62 [SD 18] years; 51% female). Median ambulance off-load times increased across the study period from 21 minutes (interquartile range [IQR] 15–30) in 2015 to 24 minutes (IQR 17–37) in 2019. Patients were divided into tertiles according to off-load times with 69,247 patients included in tertile 1 (0–17 minutes), 73,109 patients in tertile 2 (18–28 minutes), and 71,188 patients in tertile 3 (&gt;28 minutes). In multivariable models, ambulance off-load delays were associated with higher unadjusted and adjusted rates of 30-day mortality (1.57% tertile 3 vs. 1.29% tertile 1, adjusted risk difference 0.28% [95% CI 0.16% - 0.42%], p&lt;0.001) and ambulance re-attendance for chest pain (9.89% tertile 3 vs. 8.59% tertile 1, adjusted risk difference 1.30% [95% CI 1.00% - 1.61%], p&lt;0.001). Similarly, in analysis using off-load times as a continuous variable with restricted cubic splines, a non-linear increase in adjusted odds ratio for mortality was observed (Figure 1).

Conclusions

Delays in ambulance off-load times appear to be associated with increased mortality and ambulance re-attendance risk among chest pain cohorts. This study has important policy implications given the increasing frequency of off-load delays in many healthcare settings.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Alfred health

Variation in health-care quality and outcomes according to time of chest pain presentation: a state-wide prospective cohort study

Background

Previous studies examining temporal variation in cardiovascular care have largely been limited to assessing weekend and after-hours effects whereby those presenting on the weekend or after-hours have a poorer outcome. However, emerging evidence suggests more complex patterns in patterns and outcomes may exist.

Purpose

We aimed to determine patterns of temporal variation in chest pain presentations and subsequent health-care quality and outcomes.

Methods

This was an observational, prospective-cohort study of adult patients aged 18 and over who were attended by emergency medical services for non-traumatic chest pain between 1 January 2015 and 30 June 2019 in Victoria, Australia. Major exclusion criteria included pre-hospital diagnosis of ST elevation myocardial infarction or an out of hospital cardiac arrest. The exposure variable was time of day and day of week stratified into 168 hourly time periods. The primary outcome measure was 30-day mortality.

Results

The study cohort comprised 196,365 ambulance attendances for acute non-traumatic chest pain; mean age 62.4 years (SD 18.3) and 99,497 (50.7%) females. Three temporal patterns were observed for chest pain presentations (Figure 1): (1) a diurnal pattern with a sharp increase in presentations from 8 am, peaking around midday, before decreasing into late evening with a nadir between 3–4 am, (2) a weekend effect where Saturday and Sunday had a relatively lower rate of presentations compared to during the week, and (3) a Monday – Sunday gradient where more presentations were likely earlier in the week, than later. Six patterns were identified across pre-hospital and hospital key performance indicators (KPI) (diurnal, in/after-hours, weekend effect, Monday – Sunday gradient, a peak period and morning vs afternoon/evening effect. Risk of 30-day mortality was associated with weekend presentation (OR 1.15, 95% CI 1.06–1.24, p=0.001) and morning presentation between midnight and midday (OR 1.17, 95% CI 1.09–1.25, p&lt;0.001) (Figure 2).

Conclusion

Chest pain presentations, care quality and outcomes demonstrate complex temporal variation beyond the already established weekend and after-hours effect. Such relationships should be considered during resource allocation and quality improvement programs in order to improve treatment quality across all days and times of the week.

Funding Acknowledgement

Type of funding sources: None.

PSX-A-5 Late-Breaking: Branched chain amino acid and threonine requirements for puppy (&gt;14 wk-9mo) Labrador Retrievers using the indicator amino acid oxidation (IAAO) technique

Branched chain amino acids are heavily involved in protein synthesis and turnover, emphasizing the need to establish requirement for growing animals. On the other hand, threonine is vital for supporting proteins necessary for gut health. Thus, it is very important to supply branched chain amino acids and threonine in appropriate amounts to growing animals. In this experiment, the indicator amino acid oxidation (IAAO) technique was utilized to determine valine, isoleucine, leucine, and threonine requirements in six puppy Labrador Retrievers (&gt;14wk-9mo). Puppies were subjected to diets ranging from deficient to excess, with each of the indispensable amino acids formulated at 1.6x NRC values. The control diet was fed for two days of adaptation, followed by one experimental day in which the test diet was fed. On the test day, a breath sample was collected using a using a respiration mask (Oxymax, Columbus Instruments). A priming dose of L-[1-^13C]phenylalanine (Cambridge Isotope Laboratories, Inc.) based on body weight was supplied to each puppy, followed by [1-^13C]Phe doses every 30 minutes, for a four hour period. ^13CO[2] was collected after each dose and enrichment was determined by isotope ratio mass spectrometry (IRMS). Results from IRMS were converted to atom percent excess (APE) and analyzed using a segmented line model (JMP^® Pro 16). Each of the Four Rivers mean and population requirements were as follows: 1.72 ± 0.11 g/1000 kcal ME for valine; 1.43 ± 0.24 g/1000 kcal ME for isoleucine; 2.25 ± 0.15 g/1000 kcal ME for leucine; 1.74 ± 0.16 g/1000 kcal ME for threonine (mean ± 2SD). The knowledge gained from this study is highly useful as the lean mass deposited as a puppy influences the animal throughout their lifetime.

High-polyphenol extracts from Sorghum bicolor attenuate replication of Legionella pneumophila within RAW 264.7 macrophages

Polyphenols derived from a variety of plants have demonstrated antimicrobial activity against diverse microbial pathogens. Legionella pneumophila is an intracellular bacterial pathogen that opportunistically causes a severe inflammatory pneumonia in humans, called Legionnaires' Disease, via replication within macrophages. Previous studies demonstrated that tea polyphenols attenuate L. pneumophila intracellular replication within mouse macrophages via increased tumor necrosis factor (TNF) production. Sorghum bicolor is a sustainable cereal crop that thrives in arid environments and is well-suited to continued production in warming climates. Sorghum polyphenols have anticancer and antioxidant properties, but their antimicrobial activity has not been evaluated. Here, we investigated the impact of sorghum polyphenols on L. pneumophila intracellular replication within RAW 264.7 mouse macrophages. Sorghum high-polyphenol extract (HPE) attenuated L. pneumophila intracellular replication in a dose-dependent manner but did not impair either bacterial replication in rich media or macrophage viability. Moreover, HPE treatment enhanced both TNF and IL-6 secretion from L. pneumophila infected macrophages. Thus, polyphenols derived from sorghum enhance macrophage restriction of L. pneumophila, likely via increased pro-inflammatory cytokine production. This work reveals commonalities between plant polyphenol-mediated antimicrobial activity and provides a foundation for future evaluation of sorghum as an antimicrobial agent.

A Human IgSF Cell-Surface Interactome Reveals a Complex Network of Protein-Protein Interactions

Cell-surface protein-protein interactions (PPIs) mediate cell-cell communication, recognition, and responses. We executed an interactome screen of 564 human cell-surface and secreted proteins, most of which are immunoglobulin superfamily (IgSF) proteins, using a high-throughput, automated ELISA-based screening platform employing a pooled-protein strategy to test all 318,096 PPI combinations. Screen results, augmented by phylogenetic homology analysis, revealed ∼380 previously unreported PPIs. We validated a subset using surface plasmon resonance and cell binding assays. Observed PPIs reveal a large and complex network of interactions both within and across biological systems. We identified new PPIs for receptors with well-characterized ligands and binding partners for “orphan” receptors. New PPIs include proteins expressed on multiple cell types and involved in diverse processes including immune and nervous system development and function, differentiation/proliferation, metabolism, vascularization, and reproduction. These PPIs provide a resource for further biological investigation into their functional relevance and may offer new therapeutic drug targets.

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Human IgSF interactome reveals complex network of cell-surface protein interactions

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Phylogenetic homology analysis predicts protein-protein interactions

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∼380 previously unknown protein-protein interactions identified

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Deorphanization of receptors and new binding partners for well-studied receptors

Pressure injury and risk in the inpatient paediatric and neonatal populations: A single centre point-prevalence study

INTRODUCTION

Prevention and management of pressure injury is a key nurse-sensitive quality indicator. From clinical insights, pressure injury effects hospitalised neonates and children, however it is unclear how prevalent this is. The aim of this study was to quantify prevalence of pressure injury, assess skin integrity risk level, and quantify preventive interventions in both neonatal and child inpatient populations at a large children's hospital in the UK.

METHODS

A cross-sectional study was undertaken, assessing the skin integrity of all children allocated to a paediatric or neonatal bed in June/July 2020. A data collection tool was adapted from two established pressure ulcer point prevalence surveys (EUPAP and Medstrom pre-prevalence survey). Risk assessment was performed using the Braden QD scale.

RESULTS

Eighty-eight participants were included, with median age of 0.85 years [range 0-17.5 years), with 32 (36%) of participants being preterm. Median length of hospital stay was 11 days [range 0-174 days]. Pressure ulcer prevalence was 3.4%. The majority of participants had at least two medical devices, with 16 (18.2%) having more than four. Having a medical device was associated with increased risk score of developing pressure injury (odds ratio [OR] 0.03, 95% Confidence Interval [CI] 0.01-0.05, p = 0.02). Most children (39 (44%)) were reported not having proposed preventive measures in place aligned to their risk assessment. However, for those that did, 2 to 4 hourly repositioning was associated with a risk reduction on pressure damage (OR 0.13, 95% CI 0.03-0.23, p = 0.01).

CONCLUSION

Overall, we found a low prevalence of pressure injury across preterm infants, children and young people at a tertiary children's hospital. Accurate risk assessment as well as availability and implementation of preventive interventions are a priority for healthcare institutes to avoid pressure injury.

Secure Delivery of HIV-Related and Tuberculosis Laboratory Results to Patient Cell Phones: A Pilot Comparative Study

South Africa processes 5.1 million HIV CD4, viral load (VL), and tuberculosis (TB) tests annually. This pilot non-randomized trial in South Africa explored an intervention ("MatlaMobile") to deliver laboratory results via mobile phone. Adults completing CD4, VL, and/or TB laboratory tests were enrolled-either receiving results by returning to clinic (control, n = 174) or mobile phone (intervention, n = 226). Study staff instructed control participants to return within 6 days (standard-of-care). MatlaMobile instructed intervention participants with clinically actionable results requiring intervention or treatment change (i.e., < 200 CD4 cells per milliliter, ≥ 400 viral copies per milliliter, or TB positive) to return immediately. A greater proportion of intervention participants than controls saw their results within 7 days of enrollment (73% vs. 8.6%, p < 0.001). Among participants instructed to return, more intervention participants (20%, n = 14/70) returned than controls (8.6%, n = 15/174, p = 0.02). MatlaMobile demonstrated that patients can quickly receive and respond appropriately to digital delivery of health information.

Implementing a high-risk medication education introductory pharmacy practice experience

BACKGROUND AND PURPOSE

The purpose of this project was to implement a sustainable high-risk medication education (HRME) experience for student pharmacists, assess the impact on institutional metrics, and evaluate student competence.

EDUCATIONAL ACTIVITY AND SETTING

Students completed a longitudinal introductory pharmacy practice experience (IPPE) to provide patient education on anticoagulant and antiplatelet medications. Data collected included student feedback on the experience, the achievement of applicable pre-advanced pharmacy practice experience (APPE) core domains, student effect on number of patients counseled, and number of patient interactions per student.

FINDINGS

Student feedback of the HRME experience indicated that 98% either strongly agreed or agreed to meeting defined parameters. Ninety-seven percent of students completing the experience demonstrated achievement of all applicable domain abilities. Over a three-year period, students educated 1055 patients.

SUMMARY

The creation of a sustainable HRME experience for student pharmacists allowed for the achievement of applicable pre-APPE core domains. It also enhanced institutional metrics by greatly increasing the number of patient touches and providing students with direct patient care opportunities on a consistent basis.

Tumor Suppressive Activity of High Phenolic Sorghum Brans in Colon Cancer Mouse Model and Proposed Mechanisms

Objectives

Colon cancer occupy third rank in the United States and its incidence is inversely associated with high consumption of plant-based diet including whole grains. Sorghum is one of broadly cultivated crops and the bran of sorghum contains high content of bioactive compounds including polyphenols. The current study was designed to examine if different type of high phenolic sorghum brans (PI570481, SC84 and Sumac) suppress tumor formation in genetic colon cancer mouse model and elucidate related biochemical and molecular mechanisms using human colon cancer cells.

Methods

Fifty-three ApcMin/+ mice (4-week old male and female) were assigned and provided with one of following diets; 1) control (n = 11), 2) low dose of PI570481 (7.5% w/w) (n = 11), 3) high dose of PI570481 (15% w/w) (n = 11), 4) SC84 (15% w/w) (n = 10) and 5) Sumac (15% w/w) (n = 10) for 6 weeks. All mice were treated with 2% dextran sodium sulfate for one week in drinking water at 5 weeks of age. The number and size of tumor were measured from the large intestine. For in vitro study, human colon cancer cell lines were treated with different doses (0, 1.25 and 2.5 mg/mL) of high phenolic sorghum bran extracts (PI570481, SC84 and Sumac). Transcriptional activity of β-catenin was analyzed by measuring luciferase activity of reporter gene (Top and Fop flash). Gene expression was analyzed by Western blot using specific antibodies.

Results

Feeding three different types of high phenolic sorghum brans (PI570481, SC84 and Sumac) to ApcMin/+ mice for 6 weeks did not change body weight and cause any toxicity. The tumor number and tumor load in the large intestine were significantly decreased in the mice treated with three types of high phenolic sorghum brans. Regarding mechanisms, treatment of high phenolic sorghum bran extracts repressed transcriptional activity of β-catenin and IGF-1-stimulated phosphorylation of Akt in human colon cancer cells.

Conclusions

Our data propose a potential use of high phenolic sorghum brans as diets for the prevention of human colon cancer.

Funding Sources

Cooperative Agreement from USDA-ARS to University of Maryland (S-HL).

Immune Modulating Qualities of Sorghum Polyphenols

Objectives

The objective was to evaluate the potential anti-inflammatory effects of Sorghum polyphenolic extracts on raw 264.7 cells.

Methods

Sorghum polyphenols were extracted using a 70% ETOH and 5% citric acid solvent. Raw 264.7 cells were treated with either vehicle 1.25, or 0.625 mg/ml polyphenol extract from either a novel high polyphenol sorghum or SC84. Supernatant was harvested and Nitric Oxide was measured at a 12 hour time point. ELISA assay was performed to measure the concentrations of 12 anti-inflammatory associated cytokines. Cell morphology changes were observed at 3, 6, 12, and 24 hours using light microscopy. 84 genes associated with inflammation were measured via QPCR. Western blot analysis measured the expression of LC3 as well as STAT1, STAT3 and NF-kB nuclear translocation.

Results

Nitric Oxide was reduced by the sorghum extract (not significant). Cell morphology changed by  developing vacuole like structures and an apparent decrease in cell number. ELISA analysis showed that Il-6 and Il-10 were significantly reduced in all treatments. SC84 extract showed an increase in G-CSF production in activated macrophages. QPCR revealed LPS and IFNY activated cells treated with HP extract showed an increase in the expression of 9 and decreased expression of 14 cytokine related genes compared to cells that had only been activated by LPS and IFN Y. When LPS and IFN Y activated cells were cotreated with SC84 extract, 15 cytokine related genes were upregulated and 16 cytokine related genes were downregulated. LC3 expression was measured via western blot and showed a dose dependent with 1.25 mg/ml showing statistical significance. STAT3 nuclear translocation induce by LPS/IFN Y was attenuated by sorghum polyphenols.

Conclusions

The sorghum polyphenols modulated immune response via a reduction in Th2 promoting cytokines IL-6 and IL-10. LC3 II expression increased with the concentration of the HP polyphenol extract treatment, suggesting autophagy.

Funding Sources

All funding was provided by the United States Department of Agriculture.

High Polyphenol Sorghum Extract Attenuates Th2 cytokine Profile and Reduces Growth of Legionella in Raw 264.7 Mouse Macrophage Cell Line

Objectives

1) To evaluate the changes in inflammatory response induced by sorghum polyphenols in activated macrophages and 2) to evaluate possible efficacy of sorghum polyphenols on an opportunistic intracellular pathogen, Legionella pneumophila (LP).

Methods

Raw 265.7 cells mouse macrophage cells were treated with sorghum phenolic extract (SPE) under control and activating conditions to evaluate the role of SPE in inflammatory and anti-inflammatory processes. Study measured: nitric oxide production in the supernatant, mRNA using qPCR array of 84 genes in activated macrophages. Morphological changes were observed, and LC3 protein expression was measured to test for autophagy using western blot. NF-kB and STAT3 nuclear translocation was measured using a fractionization kit, followed by western blot. The replication of LP was measured within RAW 264.7 cells and in vitro (in media without cell presence). Cytotoxicity assay and a western blot apoptosis marker caspase-3 were used to evaluate the cytotoxicity of SPE on RAW 264.7 cells. Because LP reproduction within cells is greatly attenuated in the presence of Tumor Necrosis Factor (TNF), LP replication was measured under the presence of TNF neutralizing antibodies.

Results

SPE decreased nitric oxide production in activated LPS/IFNΥ macrophages although not significantly. SPE attenuated Th2 cytokine response in LPS/IFNΥ activated macrophages by decreasing expression of IL-6 and IL-10 while not changing expression of other inflammatory cytokines. Quantitative PCR data confirmed that genes in the IL-10 and IL-6 pathway were downregulated by cotreatment of SPE and LPS/IFNΥ when compared to LPS/IFNΥ alone. Morphological changes observed exhibited formation of large vacuole like structures. Analysis of LC3 confirmed that autophagy was increased in activated cells treated with SPE. Nuclear fractionization confirmed that STAT3 signaling was attenuated by SPE in activated macrophages. SPE significantly reduced the replication of LP in macrophage cells but not in vitro. The attenuation of LP grown in RAW 264.7 cells was independent of TNF presence.

Conclusions

This data suggests that sorghum phenolic compounds may have potential pharmaceutical/nutritional uses to combat intracellular pathogens.

Funding Sources

All funding was provided by the United States Department of Agriculture.

Advancing provitamin A biofortification in sorghum: Genome-wide association studies of grain carotenoids in global germplasm

Vitamin A deficiency is one of the most prevalent nutritional deficiencies worldwide. Sorghum [Sorghum bicolor L. (Moench)] is a major cereal crop consumed by millions of people in regions with high vitamin A deficiency. We quantified carotenoid concentrations in a diverse sorghum panel using high-performance liquid chromatography and conducted a genome-wide association study (GWAS) of grain carotenoids to identify genes underlying carotenoid variation. There was moderate variation for β-carotene (00.8 μg g^-1 ), lutein (0.3-9.4 μg g^-1 ), and zeaxanthin (0.2-9.1 μg g^-1 ), but β-cryptoxanthin and α-carotene were nearly undetectable. Genotype had the largest effect size, at 81% for zeaxanthin, 62% for β-carotene, and 53% for lutein. Using multiple models, GWAS identified several significant associations between carotenoids and single nucleotide polymorphisms (SNPs), some of which colocalized with known carotenoid genes that have not been previously implicated in carotenoid variation. Several of the candidate genes identified have also been identified in maize (Zea mays L.) and Arabidopsis (Arabidopsis thaliana) carotenoid GWAS studies. Notably, an SNP inside the putative ortholog of maize zeaxanthin epoxidase (ZEP) had the most significant association with zeaxanthin and with the ratio between lutein and zeaxanthin, suggesting that ZEP is a major gene controlling sorghum carotenoid variation. Overall findings suggest there is oligogenic inheritance for sorghum carotenoids and suitable variation for marker-assisted selection. The high carotenoid germplasm and significant associations identified in this study can be used in biofortification efforts to improve the nutritional quality of sorghum.

Why WIBA?

Historically, men have dominated the field of behavior analysis; however, recent trends have indicated increased participation by women. As a result of these recent changes to the field of behavior analysis, the inaugural Women in Behavior Analysis Conference (WIBA) was hosted in 2017. WIBA was initially established to highlight the accomplishments of women in the field of behavior analysis, to provide opportunities for early career behavior analysts to obtain mentorship, and to encourage meaningful discourse about gender issues in the field. Since the inaugural conference, WIBA has attempted to establish a platform for promoting gender equality but most recently has incorporated efforts related to the needs surrounding social justice and inclusiveness in the field of behavior analysis. The goal of this paper is to provide an overview of the WIBA conference. The history of WIBA is discussed, including the impetus for establishing the conference. This paper highlights existing issues on gender equality in the field of behavior analysis and the larger community, serves to demonstrate how WIBA is part of the solution, and shares accomplishments to date. Furthermore, future directions and goals are presented.

Formative research for an mHealth program to improve the HIV care continuum in South Africa

In South Africa, high attrition rates throughout the care continuum present major barriers to controlling the HIV epidemic. Mobile health (mHealth) interventions may provide innovative opportunities for efficient healthcare delivery and improving retention in care. In this formative research, we interviewed 11 patients and 28 healthcare providers in North West Province, South Africa, to identify perceived benefits, concerns and suggestions for a future mHealth program to deliver HIV Viral Load and CD4 Count test results directly to patients via mobile phone. Thematic analysis found that reduced workload for providers, reduced wait times for patients, potential expanded uses and patient empowerment were the main perceived benefits of an mHealth program. Perceived concerns included privacy, disseminating distressing results through text messages and patients' inability to interpret results. Participants felt that an mHealth program should complement face-to-face interactions and educational information to interpret results is needed. Providers identified logistical considerations and suggested protocols be developed. An mHealth program to deliver HIV test results directly to patients could mitigate multiple barriers to care but needs to be tested for efficacy. Concerns identified by patients and providers must be addressed in designing the program to successfully integrate with health facility workflow and ensure its sustainability.

Cancer Preventive Effect of a Novel High Phenolic Sorghum Bran on Human Colon Cancer Cells (P05-008-19)

Objectives

Colon cancer is one of leading causes of cancer mortality worldwide. Sorghum is the fifth most largely cultivated crop for human diet in the world. Most sorghum varieties contain high content of phenolic compounds. The objective of the current study is to evaluate the anti-cancer properties of a novel high phenolic sorghum bran extract prepared under 70% ethanol with 5% citric acid solvent.

Methods

High phenolic sorghum, accession number PI570481, was grown in Puerto Vallarta, Mexico winter nursery during the 2018 and high phenolic sorghum bran extract was prepared using 70% ethanol with 5% citric acid solvent at room temperature for 2 hours. Human colon cancer cell lines (HCT15, SW480, HCT116 and HT-29) were treated with different doses of high phenolic sorghum bran extract. Cell proliferation and apoptosis was measured using MTS assay and Alexa Fluor 488 Annexin V/Dead Cell Apoptosis system, respectively. Distribution of cell cycle was measured Texas Red channel using BD LSRFortessa system. Cell migration and invasion was measured using wound healing assay and Matrigel, respectively. The luciferase activity of reporter genes was measured using a dual-luciferase assay and Western blot was performed to measure expression of cancer phenotype-associated proteins.

Results

Cell proliferation was inhibited and apoptosis was induced in the human colon cancer cells treated with high phenolic sorghum bran extract in a dose-dependent manner. High phenolic sorghum bran extract led to S phage arrest. Cell migration and invasion was also repressed in the human colon cancer cells treated with high phenolic sorghum bran extract. The change of cancer phenotypes was associated with up- or down-regulation of regulatory genes.

Conclusions

The present study expands our understanding on the potential use of high phenolic sorghum bran for prevention of human colon cancer.

Funding Sources

Cooperative Agreement grant from USDA-ARS to S-HL.

Evaluation of ethanol-based extraction conditions of sorghum bran bioactive compounds with downstream anti-proliferative properties in human cancer cells

Certain foods such as turmeric and green tea have been extensively studied for anticancer properties, while high polyphenol sorghum has not received the same attention. Some bioactive compounds in Sorghum bicolor with anticancer activity have been identified, indicating the further need for research and screening methods of high polyphenol sorghum varieties. This study was aimed at improving the extraction of sorghum bioactive compounds by using food-grade solvents using ethanol and citric acid. We used three sorghum varieties and green tea (GT) as a control. The extraction methods were screened for anti-proliferative properties in HepG2 and HCT-15 cancer cell lines, using a cell viability assay. Extraction conditions were improved for anti-proliferative compounds from a high-phenolic sorghum variety (HP), sumac sorghum (CS), and GT. HP was more effective at inhibiting cell viability than CB, CS, and GT. The results demonstrate an efficient method for extracting sorghum bioactive compounds for future anticancer research using food approved ingredients.

Availability of Informal Caregivers for Palliative Care Patients with Cancer: Is there a Difference between Higher- and Lower-Income Settings

Objective:

Family caregivers are the default caring personnel for terminal cancer patients. The characteristics, demographics, distribution, psychological burden, and socioeconomic standards differ between high- and low-income countries. We aimed to assess those factors and their direct reflection on both the patient and the caregiver.

Patients and Methods:

This is a comparative cross-sectional study for terminal cancer patients in the palliative care unit between the United Kingdom (UK) as a high-income community and Egypt as a low-income community. We assessed the different characteristics, demographics, living place, the degree of relevance, and the availability of caregivers.

Results:

We have recruited 216 patients from the UK and 117 patients from Egypt. Informal caregivers were available in 74.5% and 92.3% for these patients with a mean age of 71.5 (standard deviation [SD] 16) years and 50.9 (SD 15.18) years, respectively. There has been a statistically significant difference between the two countries’ caregivers in being married, family, and living in the same household (P < 0.0001).

Conclusion:

Low-income countries are more common to have an informal caregiver who is a family member of different degree of relevance. Caregivers in low-income settings tend to be younger, of the female gender, married, and living in the same household than in high-income ones.

Lessons learnt from establishing a high dose opioid review clinic for people living with HIV

People living with HIV represent a unique aging population, living with a chronic condition associated with significant pain. A number take high dose, long-term opioids to manage moderate to severe chronic pain, presenting specific risks. This article highlights the size and impact of this problem and outlines the service objectives and set up of a specialist clinic to manage people living with HIV on high dose opioids, alongside its successes and learning points.

A new approach to multi-professional end of life care training using a sequential simulation (SqS Simulation™) design: A mixed methods study

BACKGROUND

A need for improved education and training for hospital staff caring for patients in the last year of life was identified at an urban UK hospital. Sequential Simulation (SqS Simulation™) is a type of simulation that recreates a patient's journey, considering the longitudinal element of care and how this might impact on the patient's experiences, wishes and needs.

OBJECTIVES

The aim of this study was to investigate a new end of life care training intervention for multi-professional hospital staff, and its effect on their confidence in managing patients at the end of their life.

SETTING/PARTICIPANTS

Based on the results of a formal Training Needs Analysis, four SqS Simulation™ specialty-based courses were designed for general medical and surgical multidisciplinary teams in an acute UK hospital.

METHODS

Over three months, seven SqS Simulation™ sessions were attended by fifty-seven multidisciplinary healthcare professionals. A quasi-experimental mixed-methods study was conducted using open and closed-ended questionnaires, pre and post-intervention. Changes in course attendees' confidence levels were analysed and qualitative data from free-text answers informed potential reasons for any differences identified.

RESULTS

Confidence improved for all professional cohorts (p < 0.001). The differences were found to be highly significant for 'doctors' (p < 0.001), significant for 'therapists' (p = 0.02) and not significant for the 'nurses' cohort (p = 0.238). This was explored further using a qualitative explanatory framework. Categories included: Communicating with Families; Teamwork; Goal Planning; Do Not Attempt Cardiopulmonary Resuscitation; Course Usefulness; Prior Training; and Clinical Experience.

CONCLUSION

This study has shown an overall improvement in confidence across disciplines after attending a SqS Simulation™ course. The differences in quantitative results between disciplines were explored through the qualitative data and revealed a difference in what the professionals gained from it. Further studies are required to assess its effectiveness in maintaining confidence of end of life care in practice, as well as its benefit to patient outcomes.