Frequent discrepancies among diagnostic tests for detecting lower esophageal sphincter-related obstruction

BACKGROUND

There are frequent discrepancies among high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and esophagram in identifying lower esophageal sphincter (LES)-related obstruction. We aimed to determine the frequency of those discrepancies and how they influenced clinical treatment/outcomes.

METHODS

We identified patients who had all three tests (HRM, FLIP, and esophagram) and endoscopy performed for evaluation of esophageal symptoms in our Center for Esophageal Diseases. Discrepancies among the tests for the presence of LES obstruction were noted, and the performance of individual tests was compared against a consensus opinion rendered by a panel of esophagologists. Binary logistical regression was performed, and ROC curves were generated for prediction of the consensus clinical diagnosis of LES obstruction.

KEY RESULTS

A total of 126 patients (mean age 57.9 ± 17.0 years; 67% female) met inclusion criteria. All three tests agreed on the presence or absence of LES obstruction in only 72 (57%) patients [no LES obstruction in 57 (45%), LES obstruction in 15 (12%)]. Thirteen patients (10%) had a change in management based on additional findings on FLIP +/- esophagram not seen on HRM with 69% having symptomatic improvement after LES-directed intervention. FLIP was the strongest predictor of a consensus diagnosis of LES obstruction by logistic regression and ROC (OR 23.36, AUC 0.796), followed by HRM (OR 15.41, AUC 0.764).

CONCLUSIONS & INFERENCE

High-resolution manometry, functional lumen imaging probe, and esophagram each have considerable limitations for identifying LES obstruction, and discrepancies among these tests occur frequently. Multimodal testing is often required for adequate evaluation of LES-related obstruction.

Exploring New Graduate Nurses' Perceptions of Factors Influencing Job Satisfaction and Resignation Ideation During COVID-19

Using an observational design, new graduate nurses' perceptions of job satisfaction and resignation ideation during COVID-19 were explored. Higher job satisfaction was associated with higher self-confidence, lower stress, and working in first choice of unit. A higher likelihood of resignation ideation was associated with coworker incivility, higher stress, and not working in first choice unit. New graduate nurses need support from nursing professional development practitioners for challenges faced throughout the transition-to-practice year.

Multidisciplinary Teamwork Perceptions When Mobilizing Ventilated Neurosurgery Patients

ABSTRACT

BACKGROUND: Multidisciplinary teamwork is essential in delivering holistic care to critically ill populations, including ventilated neurosurgery patients. Although it is considered a safe and feasible aspect of patient care, mobilization is often missed in this population because of negative healthcare provider perceptions regarding barriers and patient safety. Nurse-led teamwork has been suggested to overcome these barriers and to achieve earlier mobilization for patients, as well as positive provider perceptions, which may affect the culture and frequency of mobilization on neurointensive care units. Quantitative studies analyzing multidisciplinary teamwork perceptions to mobilize ventilated neurosurgery patients with or without a nurse-led protocol have not been previously conducted. Analyzing such perceptions may provide insight to team-related barriers related to missed mobility. This pilot quasi-experimental study aimed to determine whether the use of a nurse-led mobility protocol affects teamwork perceptions when mobilizing ventilated neurosurgery patients. METHODS: A sample of multidisciplinary teams, composed of nurses, patient care technicians, and respiratory therapists, mobilized ventilated neurosurgery patients according to either standard of care (for the control group) or a nurse-led mobility protocol (for the interventional group). Teamwork perceptions were measured via the reliable and valid Nursing Teamwork Survey tool. RESULTS: Linear mixed model analyses revealed that multidisciplinary teams in the nurse-led mobility protocol group had significantly higher levels of overall perceived teamwork than those in the control group, t3 = -3.296, P = .038. Such differences were also noted for teamwork variables of team leadership and mutual trust. CONCLUSION: Nurse-led mobility protocols should be considered to increase teamwork when performing multidisciplinary teamwork-based mobility for ventilated neurosurgery patients. Future studies should continue to evaluate teamwork perceptions after nurse-led mobility.

Acute effects of β-hydroxybutyrate on left ventricular function in young, healthy adults

Interest in ketones as a cardiac "super fuel" has grown significantly following reports of a marked increase in cardiac output after exogenous ketone administration in heart failure. However, the extent to which this increase in cardiac output is related to changes in cardiac contractility, and dependent on the presence of heart failure, remains incompletely understood. Therefore, we performed a randomized, double-blind, placebo-controlled study of oral ketone ester in young healthy volunteers. Baseline cardiac magnetic resonance imaging was performed and repeated every 15 min for 60 min after ketone and placebo ingestion to assess changes in left ventricular function. As expected, circulating β-hydroxybutyrate increased rapidly after ketone ingestion, but did not change with placebo (interaction: P < 0.001). Consistent with prior investigations, ketone ingestion resulted in an average 1 L/min increase in cardiac output after 60 min that did not occur with placebo (interaction: P = 0.026). This increase in cardiac output was primarily driven by an increase in heart rate after ketone ingestion (interaction: P = 0.018), with only a modest increase in stroke volume (interaction: P = 0.037). Changes in left ventricular strain and twist mechanics were limited. Taken together, the increase in cardiac output following an acute elevation in circulating β-hydroxybutyrate is primarily driven by changes in cardiac chronotropy, with minimal inotropic contribution.NEW & NOTEWORTHY In this randomized, double-blind, placebo-controlled study of oral ketone ester in young healthy volunteers, we show a marked increase in cardiac output (∼1 L/min), driven primarily by changes in chronotropy. The cardiac magnetic resonance imaging data support the limited role for inotropy.

Integration of longitudinal and circumferential strain predicts volumetric change across the cardiac cycle and differentiates patients along the heart failure continuum

BACKGROUND

Left ventricular (LV) circumferential and longitudinal strain provide important insight into LV mechanics and function, each contributing to volumetric changes throughout the cardiac cycle. We sought to explore this strain-volume relationship in more detail, by mathematically integrating circumferential and longitudinal strain and strain rate to predict LV volume and volumetric rates of change.

METHODS

Cardiac magnetic resonance (CMR) imaging from 229 participants from the Alberta HEART Study (46 healthy controls, 77 individuals at risk for developing heart failure [HF], 70 patients with diagnosed HF with preserved ejection fraction [HFpEF], and 36 patients with diagnosed HF with reduced ejection fraction [HFrEF]) were evaluated. LV volume was assessed by the method of disks and strain/strain rate were assessed by CMR feature tracking.

RESULTS

Integrating endocardial circumferential and longitudinal strain provided a close approximation of LV ejection fraction (EFStrain), when compared to gold-standard volumetric assessment (EFVolume: r = 0.94, P < 0.0001). Likewise, integrating circumferential and longitudinal strain rate provided a close approximation of peak ejection and peak filling rates (PERStrain and PFRStrain, respectively) compared to their gold-standard volume-time equivalents (PERVolume, r = 0.73, P < 0.0001 and PFRVolume, r = 0.78, P < 0.0001, respectively). Moreover, each integrated strain measure differentiated patients across the HF continuum (all P < 0.01), with the HFrEF group having worse EFStrain, PERStrain, and PFRStrain compared to all other groups, and HFpEF having less favorable EFStrain and PFRStrain compared to both at-risk and control groups.

CONCLUSIONS

The data herein establish the theoretical framework for integrating discrete strain components into volumetric measurements across the cardiac cycle, and highlight the potential benefit of this approach for differentiating patients along the heart failure continuum.

Reminiscence and Digital Storytelling to Improve the Social and Emotional Well-Being of Older Adults With Alzheimer's Disease and Related Dementias: Protocol for a Mixed Methods Study Design and a Randomized Controlled Trial

BACKGROUND

Increasing attention is being given to the growing concerns about social isolation, loneliness, and compromised emotional well-being experienced by young adults and older individuals affected by Alzheimer disease and related dementias (ADRD). Studies suggest that reminiscence strategies combined with an intergenerational approach may yield significant social and mental health benefits for participants. Experts also recommended the production of a digital life story book as part of reminiscence. Reminiscence is typically implemented by trained professionals (eg, social workers and nurses); however, there has been growing interest in using trained volunteers owing to staffing shortages and the costs associated with reminiscence programs.

OBJECTIVE

The proposed study will develop and test how reminiscence offered by trained young adult volunteers using a digital storytelling platform may help older adults with ADRD to improve their social and emotional well-being.

METHODS

The proposed project will conduct a randomized controlled trial to assess the effects of the intervention. The older and young adult participants will be randomly assigned to the intervention (reminiscence based) or control groups and then be randomly matched within each group. Data will be collected at baseline before the intervention, in the middle of the intervention, at end of the intervention, and at 3 months after the intervention. An explanatory sequential mixed methods design will be used to take advantage of the strengths of both quantitative and qualitative methods. The quantitative data from surveys will be entered into SPSS and analyzed using covariate-adjusted linear mixed models for repeated measures to compare the intervention and control groups over time on the major outcomes of participants. Conventional content analysis of qualitative interviews will be conducted using data analysis software.

RESULTS

The project was modified to a telephone-based intervention owing to the COVID-19 pandemic. Data collection started in 2020 and ended in 2022. In total, 103 dyads were matched at the beginning of the intervention. Of the 103 dyads, 90 (87.4%) dyads completed the midtest survey and 64 (62.1%) dyads completed the whole intervention and the posttest survey. Although we are still cleaning and finalizing data analyses, the preliminary results from both quantitative and qualitative data showed promising results of this intergenerational reminiscence approach that benefits both the older adults who have cognitive impairments and the young adult participants.

CONCLUSIONS

Intergenerational reminiscence provided by young adult college student offers promising benefits for both the younger and older generations. Future studies may consider scaling up this pilot into a trackable, replicable model that includes more participants with diverse background (eg, public vs private college students and older adults from other agencies) to test the effectiveness of this intervention for older adults with ADRD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05984732; https://classic.clinicaltrials.gov/ct2/show/NCT05984732.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49752.

The Senior Companion Program Plus for African American Caregivers of Persons With Alzheimer Disease and Related Dementias: Protocol for a Randomized Controlled Trial

BACKGROUND

Alzheimer disease and related dementias (ADRD) pose significant challenges as chronic health conditions in the United States. Additionally, there are notable disparities in the diagnosis and prevalence of ADRD among diverse populations. Specifically, African American populations have a higher risk of developing late-onset ADRD than White people, and missed diagnoses of ADRD are more common among older African American populations than older White populations. These disparities also impact African American ADRD family caregivers.

OBJECTIVE

The overall goal of this project is to develop a culturally informed, lay provider psychoeducational intervention named Senior Companion Program Plus (SCP Plus), which is specifically designed for African American ADRD caregivers and is potentially accessible, affordable, and sustainable.

METHODS

In the proposed explanatory sequential mixed methods study, a randomized controlled trial will be used that includes 114 African American family caregivers of a relative with ADRD who will participate in the 3-month SCP Plus program.

RESULTS

The study was funded on September 15, 2018, by the National Institutes of Health (1R15AG058182-01A1). Data collection began on May 16, 2019, but due to COVID-19 restrictions, ended 12 months into the planned 27-month recruitment period on March 31, 2023. The study was completed in June 30, 2023, and currently the results are being analyzed.

CONCLUSIONS

The SCP Plus offers promise as an intervention that utilizes an existing platform for the delivery of a lay provider intervention and offers a novel approach for addressing gaps in accessible, community-based support for caregivers of people with ADRD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03602391; https://classic.clinicaltrials.gov/ct2/show/NCT03602391.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/49679.

The Senior Companion Program Plus: An Innovative Training Approach for Alzheimer's Disease and Related Dementia

African Americans adults are disproportionately affected by Alzheimer's disease and related dementias (ADRD) and are underrepresented in research about ADRD. Reducing gaps in the knowledge about ADRD in the African American community is important for addressing dementia care disparities. The existing psychoeducation interventions are often limited by cost and scalability; for these reasons, lay provider (i.e., volunteer) interventions are of increasing interest in ADRD research. The purpose of this study was to evaluate a training of African American Senior Companion (SC) volunteers (n = 11) with dementia-specific knowledge (i.e., Senior Companion Program/SCP Plus), as part of a culturally informed, in-home, psychoeducational intervention for African American ADRD family caregivers. Learning outcomes were measured pre- and post-training, using the Knowledge of Alzheimer's Disease/dementia scale (KAD), the Sense of Competence Questionnaire, and the Preparedness for Caregiving Scale. The results showed significant improvements in knowledge of Alzheimer's disease/dementia, one competence item, "It is clear to me how much care my care recipient needs", and preparedness for caregiving. Overall, the study findings suggest the SCP Plus is a promising, culturally relevant, and potentially scalable lay provider training for ADRD with potential benefits that augment the existing Senior Companion Program.

Attitudes toward Aging among College Students: Results from an Intergenerational Reminiscence Project

The detrimental effects of negative attitudes toward aging among younger adults extend to both older and young adults, highlighting the need for attention from academics, applied researchers, and practitioners. To improve college students' attitudes toward aging, an intergenerational reminiscence intervention was conducted. College students, who were randomized to intervention or control groups and matched with older adults, made weekly phone calls to community-dwelling older adults with cognitive impairment for ten weeks. This study investigated whether college students improved their attitudes toward aging after participating in this project. A total of 64 college student participants completed the whole intervention and all data collection. The Fraboni Scale of Ageism was used to measure attitudes toward aging and administered at three time points (pre-, mid-, and post-test). Parametric and nonparametric tests were examined to understand changes over time, and post-hoc analyses were conducted to understand timepoints in which changes occurred. The results showed that both the intervention and control groups evidenced a decrease in the majority of the ageism scale, including statistical improvements in three specific negative items, which were "Seniors are stingy and hoard money", "Seniors live in the past", and "I prefer not to spend time with seniors". Overall, the findings indicate that weekly engagement with older adults is promising in improving attitudes toward aging among college students. Implications for future research on intergenerational contacts to improve attitudes toward aging are discussed.

Academic Differences in BSN Admission Routes: Implications for Persistence

BACKGROUND

To increase retention of prelicensure nursing students, several routes are used for admission to nursing programs. Students can be accepted as an early matriculation (EM) student at the point of university admission or they can follow a traditional competitive approach (TR) for admission.

METHOD

A retrospective matched cohort study design was used to explore the differences among selected academic variables in two groups of prelicensure undergraduate students (n = 136) in the same program.

RESULTS

EM students had significantly lower science grade point averages (GPAs), pre-program GPAs, and junior-level GPAs than TR students. However, there were no significant differences between the two groups in scores on the RN Fundamentals ATI examination, an important predictor of future NCLEX-RN success.

CONCLUSION

EM students were as successful as their counterparts on standardized examinations in the first semester of a nursing program. More research is needed to understand program outcomes associated with students entering nursing programs via different routes. [J Nurs Educ. 2023;62(5):302-306.].

The Senior Companion Program Plus (SCP Plus): Examining the Preliminary Effectiveness of a Lay Provider Program to Support African American Alzheimer's Disease and Related Dementias (ADRD) Caregivers

OBJECTIVES

A culturally informed, peer-led, lay provider model, the Senior Companion Program (SCP) Plus, was implemented to decrease caregiving burden/stress and improve coping skills and social support for African American ADRD caregivers. This study reported the preliminary effectiveness of this intervention.

METHODS

An explanatory sequential mixed methods design was used in this study, and a randomized control trial was conducted for the SCP Plus intervention among participants in three sites (n = 20). A subsample of participants (n = 7) consented to a qualitative interview about their experiences with the intervention. Wilcoxon signed-rank tests, Friedman tests, and one-way repeated measures ANOVA were computed for quantitative analyses. Thematic analysis was used for the qualitative interviews.

RESULTS

Results demonstrated that knowledge of AD/dementia (KAD) and preparedness for caregiving were significantly improved for all senior companions in the intervention group. Results also showed that caregivers in the intervention group reported significantly decreased caregiving burden, as well as increased KAD, satisfaction with social support, and positive aspects of caregiving. Themes from the qualitative interviews included: learning new skills about caregiving, gaining knowledge about ADRD, and benefits for the dyad.

DISCUSSIONS

Findings from this study implied that SCP Plus was a promising model for African American family caregivers as it benefits both the SC volunteers and the African American ADRD family caregivers.

Development and evaluation of an online vocational program for veterans with legal convictions and psychiatric illness

PURPOSE

We describe the development and pilot evaluation of an online vocational rehabilitation program, the About Face Online System (AFOS), for veterans with a history of felony convictions and either mental illness and/or substance use disorders.

METHOD

Phase One was the development and acceptability testing of the online system. Phase Two was a small, randomized trial comparing the likelihood of obtaining employment among people using the AFOS, compared to people receiving a self-directed hardcopy manual, after 6 months.

RESULTS

In Phase One, 17 veterans provided feedback as the system was being developed. The final system allows veterans to receive education on vocational reintegration skills, watch short videos describing the techniques, and communicate with a vocational staff member via chat features. Veterans found the AFOS to be as acceptable as a hardcopy manual that covered similar material. In Phase Two, 38 veterans with a history of felony convictions and either mental illness or substance use disorder were randomized to receive the AFOS or a hardcopy manual. After 6 months, people randomized to the AFOS were more likely to obtain employment than people randomized to the hardcopy manual.

CONCLUSION

An online vocational program may help veterans who cannot attend traditional in-person vocational services to successfully obtain employment.

Myocardial steatosis impairs left ventricular diastolic-systolic coupling in healthy humans

Mounting evidence suggests that myocardial steatosis contributes to left ventricular diastolic dysfunction, but definitive evidence in humans is lacking due to confounding comorbidities. As such, we utilized a 48-h food restriction model to acutely increase myocardial triglyceride (mTG) content - measured by ¹ H magnetic resonance spectroscopy - in 27 young healthy volunteers (13 men/14 women). Forty-eight hours of fasting caused a more than 3-fold increase in mTG content (P < 0.001). Diastolic function - defined as early diastolic circumferential strain rate (CSRd) - was unchanged following the 48-h fasting intervention, but systolic circumferential strain rate was elevated (P < 0.001), indicative of systolic-diastolic uncoupling. Indeed, in a separate control experiment in 10 individuals, administration of low-dose dobutamine (2 μg/kg/min) caused a similar change in systolic circumferential strain rate as was found during 48 h of food restriction, along with a proportionate increase in CSRd, such that the two metrics remained coupled. Taken together, these data indicate that myocardial steatosis contributes to diastolic dysfunction by impairing diastolic-systolic coupling in healthy adults, and suggest that steatosis may contribute to the progression of heart disease. KEY POINTS: Preclinical evidence strongly suggests that myocardial lipid accumulation (termed steatosis) is an important mechanism driving heart disease. Definitive evidence in humans is limited due to the confounding influence of multiple underlying comorbidities. Using a 48-h food restriction model to acutely increase myocardial triglyceride content in young healthy volunteers, we demonstrate an association between myocardial steatosis and left ventricular diastolic dysfunction. These data advance the hypothesis that myocardial steatosis may contribute to diastolic dysfunction and suggest myocardial steatosis as a putative therapeutic target.

Relationships Among Resilience, Stress, and Persistence in Prenursing Students During COVID-19

BACKGROUND

The coronavirus disease-2019 (COVID-19) pandemic has created personal, financial, and academic challenges for prenursing students, which may hinder academic persistence. Understanding and supporting their well-being is important, as they prepare to apply to nursing programs.

PURPOSE

The purpose of this study was to explore relationships among stress, resilience, and academic persistence in prenursing students intending to apply to either an on-campus or accelerated online nursing program.

METHODS

A cross-sectional descriptive correlational research design was used. Online survey data (N = 364) were collected during the COVID-19 pandemic.

RESULTS

Campus-based prenursing students reported higher levels of stress and lower levels of resilience than their accelerated online counterparts. A significant negative relationship was noted between stress and scores on resilience and persistence measures in both groups.

CONCLUSIONS

Program-specific interventions promoting resilience and stress management techniques are needed to support prenursing student persistence, especially as they prepare for admission to nursing programs.

Diastolic dysfunction in women with ischemia and no obstructive coronary artery disease: Mechanistic insight from magnetic resonance imaging

BACKGROUND

Ischemia with no obstructive coronary artery disease (INOCA) is prevalent in women and is associated with increased risk of developing heart failure with preserved ejection fraction (HFpEF); however, the mechanism(s) contributing to this progression remains unclear. Given that diastolic dysfunction is common in women with INOCA, defining mechanisms related to diastolic dysfunction in INOCA could identify therapeutic targets to prevent HFpEF.

METHODS

Cardiac MRI was performed in 65 women with INOCA and 12 reference controls. Diastolic function was defined by left ventricular early diastolic circumferential strain rate (eCSRd). Contributors to diastolic dysfunction were chosen a priori as coronary vascular dysfunction (myocardial perfusion reserve index [MPRI]), diffuse myocardial fibrosis (extracellular volume [ECV]), and aortic stiffness (aortic pulse wave velocity [aPWV]).

RESULTS

Compared to controls, eCSRd was lower in INOCA (1.61 ± 0.33/s vs. 1.36 ± 0.31/s, P = 0.016); however, this difference was not exaggerated when the INOCA group was sub-divided by low and high MPRI (P > 0.05) nor was ECV elevated in INOCA (29.0 ± 1.9% vs. 28.0 ± 3.2%, control vs. INOCA; P = 0.38). However, aPWV was higher in INOCA vs. controls (8.1 ± 3.2 m/s vs. 6.1 ± 1.5 m/s; P = 0.045), and was associated with eCSRd (r = -0.50, P < 0.001). By multivariable linear regression analysis, aPWV was an independent predictor of decreased eCSRd (standardized β = -0.39, P = 0.003), as was having an elevated left ventricular mass index (standardized β = -0.25, P = 0.024) and lower ECV (standardized β = 0.30, P = 0.003).

CONCLUSIONS

These data provide mechanistic insight into diastolic dysfunction in women with INOCA, identifying aortic stiffness and ventricular remodeling as putative therapeutic targets.

Relationships among stress, resilience, and incivility in undergraduate nursing students and faculty during the COVID-19 pandemic: Policy implications for nurse leaders

BACKGROUND

Developing successful targeted interventions to reduce incivility for undergraduate nursing students and educators will require understanding the differences in their unique experiences. Although resilience may act as protective buffer against stressors, little is known about the relationships between stress, resilience, and perceptions of the frequency of incivility in the academic environment.

PURPOSE

The purpose of this study was to compare relationships among and differences between perceptions of incivility frequency and self-reported stress and resilience levels in undergraduate nursing students and faculty during the COVID-19 pandemic.

METHOD

A comparative descriptive and correlational research design was utilized. An online survey was used to collect data from undergraduate nursing students and faculty (n = 710) at one public university.

RESULTS

Students were significantly more stressed and less resilient than faculty. Faculty reported significantly greater low and high-level student and low-level faculty incivility behaviors than students.

CONCLUSION

Understanding student and faculty perceptions of uncivil behavior frequency occurring at the intersection of high stress and moderate resilience levels is key to the creation of targeted interventions and policy development.

Blending Traditional Vocational Services and Individualized Placement and Support for Formerly Incarcerated Veterans

OBJECTIVE

This study compared two vocational programs: the About Face Vocational Program (AFVP), a traditional group-based vocational program created for formerly incarcerated veterans, and a hybrid program combining the AFVP with principles of individual placement and support-supported employment.

METHODS

The study evaluated 111 veterans with at least one felony conviction who had a mental illness, substance use disorder, or both. Veterans were randomly assigned to either vocational condition.

RESULTS

Veterans in the hybrid condition, compared with the AFVP alone, were more likely to find employment, had higher rates of full-time employment, and earned significantly more money over the course of the study. A comparison of only participants who found employment showed higher rates of full-time employment for veterans in the hybrid condition but similarities between the two groups in other measures of employment success.

CONCLUSIONS

Blended models of vocational services for veterans with mental illness, substance use disorders, or both are effective at returning formerly incarcerated veterans to competitive employment.

Rates of Adverse IBD-Related Outcomes for Patients With IBD and Concomitant Prostate Cancer Treated With Radiation Therapy

BACKGROUND

Patients with inflammatory bowel disease (IBD) may be at higher risk for complications from radiation treatment for prostate cancer. However, available data are limited, and controversy remains regarding the best treatment approach for IBD patients who develop prostate cancer.

METHODS

A retrospective cohort study across 4 Department of Veterans Affairs hospital systems. Patients with established IBD who were diagnosed and treated for prostate cancer between 1996-2015 were included. We assessed for flares of IBD, IBD-related hospitalizations, and IBD-related surgeries within 6, 12, and 24 months of cancer diagnosis and survival at 1, 2, and 5 years. Flares of IBD were those documented as such by the treating physician, and treatment changed accordingly.

RESULTS

One hundred patients with IBD and prostate cancer were identified. Forty-seven were treated with either treatment with external beam radiation or brachytherapy, and 53 were treated with nonradiation modalities. Comparing cohorts with or without radiation treatment, there were no differences in baseline IBD characteristics, Charlson comorbidity index, or prostate cancer stage. Inflammatory bowel disease flares were 2-fold higher for radiation-treated patients within 6 months (10.6% vs 5.7%) and 6-12 months (4.3% vs 1.9%) after cancer diagnosis. On multiple logistic regression analysis, radiation treatment (adjusted odds ratio, 4.82; 95% confidence interval, 1.15-20.26) was a significant predictor of flares. However, rates of IBD-related hospitalizations or surgeries were not significantly different.

CONCLUSIONS

In this retrospective, multicenter study, 2-fold higher rates of flare were found within the first year after prostate cancer diagnosis for patients treated with radiation, but there were no differences in IBD-related hospitalizations or surgeries. Although patients should be counseled of these risks, avoidance of radiation therapy in IBD patients with prostate cancer is likely not necessary.

Safety of tumor necrosis factor inhibitor use in patients with concomitant malignancy

Background/Aims

Safety for tumor necrosis factor inhibitors (TNFi) in cancer has been focused on risk of incident malignancies, but studies on prognostic effects have been scarce. We determined survival and recurrence rates at 1, 2, and 5 years after cancer diagnosis in patients with and without concurrent TNFi use.

Methods

Chart reviews were performed between 1996 and 2015 at the VA North Texas Healthcare System. Cases were patients with inflammatory disease, concomitant malignancy, and TNFi use while controls were patients with inflammatory disease, concomitant malignancy but no TNFi use. Cases and controls were matched for type of malignancy. Analysis was performed with log-rank tests on Kaplan-Meier curves.

Results

Thirty-six cases and 72 controls were identified. For cases, survival at 1, 2, and 5 years were 32 (89%), 31 (86%), and 29 (81%) compared to 63 (90%), 61 (87%), and 51 (73%) for the control group (P=0.985). For cases, recurrence rates at 1, 2, and 5 years were 3 (8%), 5 (14%), and 6 (17%) compared to 2 (3%), 5 (7%), and 7 (10%) for the control group (P=0.158).

Conclusions

Our findings suggest TNFi may be safely used in select inflammatory disease patients with concurrent cancer if therapy is needed for proper disease control. However, case-by-case consideration in conjunction with an oncologist is recommended while considering the apparent safety of TNFi for patients suffering from active inflammatory diseases despite having a concomitant malignancy.

High Prevalence of Male Sexual Dysfunction in a Prospective Multicenter VA Inflammatory Bowel Disease Population

Background

Aims of this study were to assess the prevalence of and risk factors for sexual dysfunction (SD) in male veterans with inflammatory bowel disease (IBD).

Methods

We collected IBD history, quality of life (QOL), and sexual function surveys.

Results

One hundred seventy-one men enrolled, mean age 50 years, 85% had SD, 92% had erectile dysfunction (ED). More severe ED (P = 0.0001), decreased sexual desire (P = 0.004), and decreased satisfaction (P = 0.001) were associated with poorer QOL. Biologic use was associated with increased SD; hypertension with a decrease in sexual desire.

Conclusions

SD and ED are highly prevalent and associated with poorer QOL.

Efficacy of Prophylactic Hemoclips in Prevention of Delayed Post-Polypectomy Bleeding in Patients With Large Colonic Polyps

BACKGROUND & AIMS

The efficacy of prophylactic placement of hemoclips to prevent delayed bleeding after removal of large colonic polyps has not been established. We conducted a randomized equivalence study to determine whether prophylactic placement of hemoclips affects incidence of delayed post-polypectomy bleeding (PPB).

METHODS

During elective colonoscopy performed at 4 Veterans Affairs Medical Centers, 1098 patients who had polyps ≥1 cm removed were randomly assigned to groups that received prophylactic hemoclips (n = 547) or no hemoclips (n = 551), from September 2011 through September 2018. Data on PPB (rectal bleeding resulting in hemoglobin decreases ≥2 g/dL, hemodynamic instability, colonoscopy, angiography, or surgery) within 30 days of colonoscopy (called delayed PPB) were collected during telephone interviews or hospital visits 7 and 30 days after colonoscopy. The primary outcome was the incidence of important post-polypectomy bleeding.

RESULTS

Twelve patients in the hemoclip group (2.3%) and 15 patients in the no hemoclip group (2.9%) had important delayed PPB. There were no deaths, and no patients in either group required angiography or surgery. In intention-to-treat analysis, two 1-sided test's lower and upper confidence interval limits were -2.07 and 1.01, indicating that the data approached but did not meet equivalence criteria. On multiple logistic regression analysis, significant predictors of PPB included use of warfarin with bridging, thienopyridines, polyp size, and polyp location, but hemoclip placement did not associate with important delayed PPB.

CONCLUSIONS

In a randomized trial, we found that prophylactic placement of hemoclips after removal of large colon polyps does not affect the proportion of important delayed PPB events, compared with no hemoclip placement. These findings call into question the widespread, expensive practice of routinely placing prophylactic hemoclips after polypectomy. ClinicalTrials.gov ID: NCT01647581.

Interindividual differences in the ischemic stimulus and other technical considerations when assessing reactive hyperemia

Reactive hyperemia is an established, noninvasive technique to assess microvascular function and a powerful predictor of all-cause and cardiovascular morbidity and mortality. Emerging evidence from our laboratory suggests a close link between reactive hyperemia and the metabolic rate of the ischemic limb and the existence of large interindividual differences contributing to markedly different stimuli to vasodilate. Here we relate forearm tissue desaturation (i.e., the ischemic stimulus to vasodilate, measured by near-infrared spectroscopy) to brachial artery hyperemic velocity and flow (measured using duplex ultrasound) across a wide range of ischemic stimuli. Twelve young and 11 elderly individuals were prospectively studied. To recapitulate conventional vascular occlusion testing, reactive hyperemia was first assessed using a standard 5-min occlusion period. Then, to evaluate the dose dependence of tissue ischemia on reactive hyperemia, we randomly performed 4-, 6-, and 8-min cuff occlusions in both groups. In all cases, peak velocity, as well as the 5-s average velocity, immediately after the cuff occlusion was significantly higher in the young than the elderly group; however, tissue desaturation was also much more pronounced in the young group (P < 0.05), representing a greater ischemic stimulus. Remarkably, when reactive hyperemia was adjusted for the ischemic vasodilatory stimulus, group differences in reactive hyperemia were abrogated. Together, these data challenge conventional interpretations of reactive hyperemia and show that the ischemic stimulus to vasodilate varies across individuals and that the level of reactive hyperemia is often coupled to the magnitude of tissue desaturation.

Implementation and initial outcomes of a spinal cord injury home care program at a large veterans affairs medical center

OBJECTIVES

Describe an interdisciplinary spinal cord injury home care program (SCIHCP), sample demographics for the veteran participants, and initial impact of SCIHCP on health care utilization and mortality.

DESIGN

Retrospective review.

SETTING

SCIHCP of the Spinal Cord Injury Center, VA North Texas Health Care System (VANTHCS).

PARTICIPANTS

Patients with SCI/D enrolled in the SCIHCP during January 6, 2006 through January 9, 2012, whose injury occurred at least one year prior to enrollment(n = 125).

MAIN OUTCOME MEASURES

VANTHCS hospital admissions, length of stay (LOS), and emergency department (ED) visits evaluated one year before and one year after SCIHCP enrollment; mortality evaluated one-year post-enrollment.

RESULTS

There were no significant changes in number of ED visits, number of hospital admissions, or LOS over time. More home care visits and more mental health comorbidities predicted more hospital admissions. Older patients and those with more mental health comorbidities were more likely to experience increases in LOS. These prediction models were significant after adjusting for injury level, age, race, time since SCI, and number of medical comorbidities. More home care visits were associated with lower likelihood of mortality post-enrollment.

CONCLUSIONS

Inpatient and ED utilization did not change one year after enrollment, but more SCIHCP visits predicted more hospital admissions and lower likelihood of mortality in the post-evaluation year. The support, education, and care continuity SCIHCP generates might be related to increased inpatient access and lower mortality rate. Veterans with increased mental health comorbidities used inpatient services more, and might need additional support.

Online Course Engagement Among Undergraduate Nursing Student Veterans

As a result of the Post-9/11 Veterans Assistance Act, academic programs aimed at assisting student veterans to become Registered Nurses (RN) are increasing. Accordingly, the number of nursing academic programs being offered online are increasing, yet little is known about online student veterans’ behaviors within learning management systems (LMS). This study examined the patterns of LMS use among student veterans who are pursuing a Bachelor of Science in Nursing (BSN) and the association between these behaviors and academic success. A retrospective associational analysis was conducted with data collected from students enrolled in courses in an online BSN program. The multilevel data consisted of 528 students who took one or more of twelve courses. The sample consisted of 23 veterans and 505 non-veteran BSN (non-VBSN) students in 3,793 course enrollments. Veterans were more likely to be male and were less likely to be classified as an in-state resident. Overall, the students engaged in their LMS early and most did not have missing or late assignments. The amount of online time spent in each course and the number of late assignment submissions significantly predicted course grades. No other significant predictors of graduation, discontinuation, or grades emerged. Notwithstanding some demographic differences, veterans appeared to be comparable to their non-VBSN counterparts overall, in terms of both academic performance and online engagement. These results indicate that the time students spend in their online courses can predict program success. The creation of an early-identification process for at-risk students who are not engaging in their LMS might have the potential to enhance educational outcomes even further.

Incidence of Colorectal Cancer and Extracolonic Cancers in Veteran Patients With Inflammatory Bowel Disease

Background

The risk for colorectal cancer (CRC) and certain extracolonic cancers is thought to be increased in inflammatory bowel disease (IBD), but few recent US studies have evaluated this issue. We aimed to estimate the incidence of CRC and extracolonic cancers in IBD patients.

Methods

In this case-control study, cases were all IBD patients treated in our Department of Veterans Affairs (VA) hospital who developed CRC or extracolonic cancers between 1996 and 2015. Controls were patients in the general VA population who developed these cancers during the same time. We compared cancer incidence rates (IRs) in cases and controls.

Results

There was no significant difference between cases and controls in the 20-year IR for CRC (148/100 000 in IBD patients, 97/100 000 in controls; relative risk [RR], 1.53; 95% confidence interval [CI], 0.86-2.69). In contrast, IBD cases had a significantly higher 20-year IR for all extracolonic cancers than controls (2839/100 000 in IBD patients, 1960/100 000 in controls; RR, 1.45; 95% CI, 1.27-1.65). Site-specific analyses revealed that IBD patients had significantly elevated risks for nonmelanoma skin cancers (RR, 2.38; 95% CI, 1.99-2.85), melanoma skin cancers (RR, 2.85; 95% CI, 1.63-4.88), renal tumors (RR, 2.90; 95% CI, 1.46-5.84), prostate cancer (RR, 1.70; 95% CI, 1.28-2.27), and pancreatic cancer (RR, 4.23; 95% CI, 1.35-13.29).

Conclusions

The incidence of CRC was not significantly higher in our veteran patients with IBD than in control patients in the general VA population. In contrast, our IBD patients had a significantly higher risk for extracolonic cancers than controls, including cancers of the skin, kidneys, prostate, and pancreas. 10.1093/ibd/izx046_video1Video 1.izx046_Mosher_Video5734484616001.

Factors Associated With Length of Stay in Veterans With Inflammatory Bowel Disease Hospitalized for an Acute Flare

BACKGROUND

Reducing hospital costs and risk of complications by shortening length of stay has become paramount. The aim of our study was to identify predictors and potentially modifiable factors that influence length of stay among veterans with inflammatory bowel disease admitted for an acute flare.

METHODS

Retrospective review of patients admitted to the Dallas VA with an acute flare of their inflammatory bowel disease between 2000 and 2015. Patients with a length of stay of ≤4 days were compared with those whose length of stay >4 days.

RESULTS

A total of 180 admissions involving 113 patients (59 with ulcerative colitis and 54 with Crohn's disease) were identified meeting inclusion criteria. The mean length of stay was 5.3 ± 6.8 days, and the median length of stay was 3.0 days. On multiple logistic regression analysis, initiation of a biologic, having undergone 2 or more imaging modalities, and treatment with intravenous steroids were significant predictors of longer lengths of stay, even after controlling for age and comorbid diseases.

CONCLUSIONS

We identified several predictors for longer hospital length of stay, most related to disease severity but several of which may be modifiable to reduce hospital stays, including most importantly consideration of earlier prebiologic testing. Future studies are needed to evaluate the impact of interventions targeting modifiable predictors of length of stay on health care utilization and patient outcomes.

Demographic and Academic Factors Associated With Enrollment in Online MSN Programs

BACKGROUND

There is a need to better understand the demographic and academic characteristics of individuals enrolled in online Master of Science in Nursing (MSN) programs.

METHOD

This article reports a retrospective analysis of 4,079 students enrolled in one of three MSN programs: family nurse practitioner (FNP), nurse educator, and nursing administration. Demographic characteristics (i.e., gender, race, age) and academic variables (i.e., academic load, past undergraduate/graduate enrollment at the university) were examined for all enrollees.

RESULTS

Students in the MSN programs were younger than the national mean age for RNs, were primarily White, and were enrolled part time. The sample was composed of a disproportionately higher percentage of students from ethnic minority backgrounds than national RN profiles.

CONCLUSION

Study implications indicate that understanding the commonalities, differences, and educational experiences of students in on-campus and online MSN programs is important. The finding that almost 90% of online graduate nursing students enroll as part time has significant financial, family, and career implications. [J Nurs Educ. 2017;56(11):670-674.].

Hypoxia-inducible factor-2α plays a role in mediating oesophagitis in GORD

OBJECTIVE

In an earlier study wherein we induced acute reflux by interrupting proton pump inhibitor (PPI) therapy in patients with reflux oesophagitis (RO) healed by PPIs, we refuted the traditional concept that RO develops as an acid burn. The present study explored our alternative hypothesis that RO results from reflux-stimulated production of pro-inflammatory molecules mediated by hypoxia-inducible factors (HIFs).

DESIGN

Using oesophageal biopsies taken from patients in our earlier study at baseline and at 1 and 2 weeks off PPIs, we immunostained for HIF-1α, HIF-2α and phospho-p65, and measured pro-inflammatory molecule mRNAs. We exposed human oesophageal squamous cell lines to acidic bile salts, and evaluated effects on HIF activation, p65 function, pro-inflammatory molecule production and immune cell migration.

RESULTS

In patient biopsies, increased immunostaining for HIF-2α and phospho-p65, and increased pro-inflammatory molecule mRNA levels were seen when RO redeveloped 1 or 2 weeks after stopping PPIs. In oesophageal cells, exposure to acidic bile salts increased intracellular reactive oxygen species, which decreased prolyl hydroxylase function and stabilised HIF-2α, causing a p65-dependent increase in pro-inflammatory molecules; conditioned media from these cells increased T cell migration rates. HIF-2α inhibition by small hairpin RNA or selective small molecule antagonist blocked the increases in pro-inflammatory molecule expression and T cell migration induced by acidic bile salts.

CONCLUSIONS

In patients developing RO, increases in oesophageal HIF-2α correlate with increased pro-inflammatory molecule expression. In oesophageal epithelial cells, acidic bile salts stabilise HIF-2α, which mediates expression of pro-inflammatory molecules. HIF-2α appears to have a role in RO pathogenesis.

TRIAL REGISTRATION NUMBER

NCT01733810; Results.

Patients with cirrhosis who have coronary artery disease treated with cardiac stents have high rates of gastrointestinal bleeding, but no increased mortality

BACKGROUND

Patients with coronary artery disease (CAD) treated with stents require dual antiplatelet therapy (DAPT). For cirrhotics, who often have varices and coagulopathy, it is not clear if the risk of gastrointestinal bleeding (GIB) should preclude use of DAPT.

AIM

To compare GIB and mortality rates in cirrhotics with CAD treated medically or with stents.

METHODS

Using institutional databases, we identified patients with cirrhosis and CAD treated with stents or medical therapy between January 2000-September 2015. Primary outcomes were GIB and mortality.

RESULTS

We identified 148 cirrhotics with CAD; 68 received stents (cases), 80 were treated with medical therapy (controls). Cases and controls had similar demographics, comorbidities, MELD scores and clinical presentation; DAPT was used in 98.5% of cases vs 5% of controls. The incidence of GIB was significantly higher in cases than controls (22.1% vs 5% at 1 year, P=.003; 27.9% vs 5% at 2 years, P=.0002), whereas all-cause mortality was similar (20.6% vs 21.3%). No patient required surgery or angiography for GIB, and no known patients died due to GIB. Multivariate analysis revealed use of a proton pump inhibitor (PPI) was highly protective against GIB (OR=0.26, 95%CI=0.08-0.79).

CONCLUSIONS

CAD treatment with stents in our cirrhotics was associated with a significantly increased risk of GIB, but no adverse effects on survival. Although it remains unclear whether the cardiovascular benefits of stents outweigh the GIB risk, our findings suggest that DAPT should not be withheld from stented cirrhotics for fear of GIB. Moreover, the use of a PPI should be strongly considered.

Vocational rehabilitation for veterans with felony histories and mental illness: 12-month outcomes

Lack of employment is an important barrier to successful reintegration encountered by those released from prison with mental illnesses and/or substance use disorders. This study compares 3 different vocational reintegration modalities for a veteran population: (a) basic services; (b) self-study using the About Face Vocational Manual; and (c) the About Face Vocational Program, a standardized group program focused on the About Face Vocational Manual. One-hundred eleven veterans with a history of at least one felony conviction and a mental illness and/or substance use disorder were recruited from a large urban Veterans Affairs (VA) medical center. Veterans were assigned to 1 of the 3 conditions and followed for 12 months. At the end of the 1-year follow-up period, veterans in the group condition had superior competitive and stable employment rates, as well as faster times to employment compared with both the basic and self-study conditions. The self-study condition was generally indistinguishable from the basic services condition. Overall, new employment during the last 6 months of the follow-up period was relatively low. The findings support the use of standardized group vocational reintegration programs such as the About Face Vocational Program. Limitations and implications are discussed. (PsycINFO Database Record

Incorporating Individualized Placement and Support Principles Into Vocational Rehabilitation for Formerly Incarcerated Veterans

OBJECTIVE

This study evaluated the six-month outcomes of incorporating the principles of supported employment, specifically Individual Placement and Support (IPS), into the About Face program, an existing standardized group-based vocational program for previously incarcerated veterans.

METHODS

Participants (N=84) with a history of at least one felony conviction and a substance use disorder (88%) or mental illness or combination (59%) were recruited from a large urban veterans hospital. Veterans were randomly assigned to either the About Face program (AF) or to that program plus a modification of IPS (AF+IPS). Veterans were followed for six months. Employment outcomes, including time to employment, hours worked, and income earned, were evaluated with survival analyses and nonparametric tests.

RESULTS

Rates of employment over the follow-up period were significantly higher for those receiving AF+IPS, with 21 of 46 (46%) finding employment, compared with only eight of 38 (21%) who received AF alone. As a group, those receiving AF+IPS worked more hours and earned more wages than those receiving AF alone.

CONCLUSIONS

Incorporating many of the principles and techniques of IPS into an existing vocational program was associated with improved employment outcomes over the six-month follow-up period and should be considered a viable rehabilitation option when working with this vulnerable population.

Association of Acute Gastroesophageal Reflux Disease With Esophageal Histologic Changes

IMPORTANCE

The histologic changes associated with acute gastroesophageal reflux disease (GERD) have not been studied prospectively in humans. Recent studies in animals have challenged the traditional notion that reflux esophagitis develops when esophageal surface epithelial cells are exposed to lethal chemical injury from refluxed acid.

OBJECTIVE

To evaluate histologic features of esophageal inflammation in acute GERD to study its pathogenesis.

DESIGN, SETTING, AND PARTICIPANTS

Patients from the Dallas Veterans Affairs Medical Center who had reflux esophagitis successfully treated with proton pump inhibitors (PPIs) began 24-hour esophageal pH and impedance monitoring and esophagoscopy (including confocal laser endomicroscopy [CLE]) with biopsies from noneroded areas of distal esophagus at baseline (taking PPIs) and at 1 week and 2 weeks after stopping the PPI medication. Enrollment began May 2013 and follow-up ended July 2015.

INTERVENTIONS

PPIs stopped for 2 weeks.

MAIN OUTCOMES AND MEASURES

Twelve patients (men, 11; mean age, 57.6 year [SD, 13.1]) completed the study. Primary outcome was change in esophageal inflammation 2 weeks after stopping the PPI medication, determined by comparing lymphocyte, eosinophil, and neutrophil infiltrates (each scored on a 0-3 scale) in esophageal biopsies. Also evaluated were changes in epithelial basal cell and papillary hyperplasia, surface erosions, intercellular space width, endoscopic grade of esophagitis, esophageal acid exposure, and mucosal impedance (an index of mucosal integrity).

RESULTS

At 1 week and 2 weeks after discontinuation of PPIs, biopsies showed significant increases in intraepithelial lymphocytes, which were predominantly T cells (median [range]: 0 (0-2) at baseline vs 1 (1-2) at both 1 week [P = .005] and 2 weeks [P = .002]); neutrophils and eosinophils were few or absent. Biopsies also showed widening of intercellular spaces (confirmed by CLE), and basal cell and papillary hyperplasia developed without surface erosions. Two weeks after stopping the PPI medication, esophageal acid exposure increased (median: 1.2% at baseline to 17.8% at 2 weeks; Δ, 16.2% [95% CI, 4.4%-26.5%], P = .005), mucosal impedance decreased (mean: 2671.3 Ω at baseline to 1508.4 Ω at 2 weeks; Δ, 1162.9 Ω [95% CI, 629.9-1695.9], P = .001), and all patients had evidence of esophagitis.

CONCLUSIONS AND RELEVANCE

In this preliminary study of 12 patients with severe reflux esophagitis successfully treated with PPI therapy, stopping PPI medication was associated with T lymphocyte-predominant esophageal inflammation and basal cell and papillary hyperplasia without loss of surface cells. If replicated, these findings suggest that the pathogenesis of reflux esophagitis may be cytokine-mediated rather than the result of chemical injury.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01733810.

Clinical Utility of the Japan-Chronic Total Occlusion Score in Coronary Chronic Total Occlusion Interventions: Results from a Multicenter Registry

BACKGROUND

The performance of the Japan-chronic total occlusion (J-CTO) score in predicting success and efficiency of CTO percutaneous coronary intervention has received limited study.

METHODS AND RESULTS

We examined the records of 650 consecutive patients who underwent CTO percutaneous coronary intervention between 2011 and 2014 at 6 experienced centers in the United States. Six hundred and fifty-seven lesions were classified as easy (J-CTO=0), intermediate (J-CTO=1), difficult (J-CTO=2), and very difficult (J-CTO≥3). The impact of the J-CTO score on technical success and procedure time was evaluated with univariable logistic and linear regression, respectively. The performance of the logistic regression model was assessed with the Hosmer-Lemeshow statistic and receiver operator characteristic curves. Antegrade wiring techniques were used more frequently in easy lesions (97%) than very difficult lesions (58%), whereas the retrograde approach became more frequent with increased lesion difficulty (41% for very difficult lesions versus 13% for easy lesions). The logistic regression model for technical success demonstrated satisfactory calibration and discrimination (P for Hosmer-Lemeshow =0.743 and area under curve =0.705). The J-CTO score was associated with a 2-fold increase in the odds of technical failure (odds ratio 2.04, 95% confidence interval 1.52-2.80, P<0.001). Procedure time increased by ≈20 minutes for every 1-point increase of the J-CTO score (regression coefficient 22.33, 95% confidence interval 17.45-27.22, P<0.001).

CONCLUSIONS

J-CTO score was strongly associated with final success and efficiency in this study, supporting its expanded use in CTO interventions.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02061436.

Obesity in Inflammatory Bowel Disease: A Marker of Less Severe Disease

BACKGROUND

Both obesity and inflammatory bowel disease (IBD) are highly prevalent in Western societies. IBD, including Crohn's disease (CD) and ulcerative colitis (UC), has been historically associated with cachexia and malnutrition. It is uncertain how obesity, a chronic pro-inflammatory state, may impact the course of IBD.

AIM

The aim of this study was to report the prevalence of obesity in patients with IBD in a metropolitan US population and to assess the impact of obesity on disease phenotypes, treatment, and surgical outcomes in IBD patients.

METHODS

We reviewed the medical records of patients identified from the IBD registries of the Dallas Veterans Affairs Medical Center and Parkland Health and Hospital Systems who were seen from January 1, 2000, to December 31, 2012.

RESULTS

Of 581 identified IBD patients, 32.7 % were obese (BMI ≥ 30) and 67.6 % were non-obese (BMI < 30). There were 297 (51.1 %) patients with CD and 284 (48.9 %) patients with UC. The rate of obesity was 30.3 % among CD patients and 35.2 % among UC patients. Overall, obese patients were significantly less likely to receive anti-TNF treatment, undergo surgery, or experience a hospitalization for their IBD than their non-obese counterparts (55.8 vs. 72.1 %, p = .0001).

CONCLUSION

Obesity is highly prevalent in our IBD patients, paralleling the obesity rates in the US population. Clinical outcomes were significantly different in obese versus non-obese patients with IBD. Despite the plausible mechanisms whereby obesity might exacerbate IBD, we have found that obesity (as defined by BMI) is a marker of a less severe disease course in IBD.

Parent Health Literacy and Communication With Diabetes Educators in a Pediatric Diabetes Clinic: A Mixed Methods Approach

Low health literacy is associated with poor communication between adults and providers, but little is known about how parents' health literacy influences communication in pediatric encounters. We examined how parent health literacy affected communication between parents and diabetes educators in a pediatric diabetes clinic. A mixed methods study was conducted including a cross-sectional survey of 162 parents and semi-structured interviews with a subsample of 24 parents of a child with Type 1 diabetes. Parent and child characteristics, parents' report of quality of communication, and parent health literacy were assessed. Logistic regression was performed to determine associations between health literacy and 4 subscales of the Interpersonal Processes of Care (IPC) survey; directed content analyses of interview data were completed. Although health literacy was not significantly associated with the IPC subscales, results from directed content analyses revealed different communication experiences for parents by health literacy classification. Low health literate parents were confused by diabetes jargon, preferred hands-on teaching, and wished for information to be communicated in simple language, broken down into key points, and repeated. Parents with adequate health literacy wanted comprehensive information communicated through ongoing dialogue. Findings indicate that learner-driven curricula may be most appropriate for diabetes education.

Effect of a Real-Time Radiation Monitoring Device on Operator Radiation Exposure During Cardiac Catheterization

Background—

The Radiation Reduction During Cardiac Catheterization Using Real-Time Monitoring study sought to examine the effect of a radiation detection device that provides real-time operator dose reporting through auditory feedback (Bleeper Sv; Vertec Scientific Ltd; Berkshire, UK) on patient dose and operator exposure during cardiac catheterization.

Methods and Results—

Between January 2012 and May 2014, 505 patients undergoing coronary angiography, percutaneous coronary intervention, or both were randomized to use (n=253) or no use (n=252) of the Bleeper Sv radiation monitor. Operator radiation exposure was measured in both groups using a second, silent radiation exposure monitoring device. Mean patient age was 65±8 years, most patients (99%) were men, and 30% had prior coronary artery bypass graft surgery. Baseline clinical characteristics were similar in the 2 study groups. Radial access was used in 18% and chronic total occlusion percutaneous coronary intervention constituted 7% of the total procedures. Median procedure time was 17 (12–27) minutes for diagnostic angiography, 42 (28–70) minutes for percutaneous coronary intervention, and 27 (14–51) minutes in the overall study population, with similar distribution between the study groups. First (9 [4–17] versus 14 [7–25] μSv; P <0.001) and second (5 [2–10] versus 7 [4–14] μSv; P <0.001) operator radiation exposure was significantly lower in the Bleeper Sv group. Use of the device did not result in a significant reduction in patient radiation dose. The effect of the Bleeper Sv device on operator radiation exposure was consistent among various study subgroups.

Conclusions—

Use of a real-time radiation monitoring device that provides auditory feedback can significantly reduce operator radiation exposure during cardiac catheterization.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01510353.

Use of a Carbon Dioxide Laser as an Adjunct to Scaling and Root Planing for Clinical New Attachment: A Case Series

INTRODUCTION

Severe, chronic periodontitis (CP) is typically treated either with scaling and root planing (SRP) or surgical therapy in an effort to gain clinical attachment. The advantage of non-surgical therapy is decreased morbidity to the patient; however, the site typically heals by formation of a long junctional epithelium. The advantage of surgical therapy is access for debridement and the use of bone or bone substitutes in combination with a barrier membrane for epithelial exclusion. Compared with a non-surgical approach, surgical therapy is more invasive, and patient acceptance of treatment is typically more challenging. The use of lasers in dentistry appears to be rapidly increasing, as evidenced by the influx of new lasers into the dental market as well as numerous anecdotal reports of beneficial results with their use.

CASE SERIES

This report presents a novel approach to the treatment of severe CP using a carbon dioxide (CO₂) laser in combination with SRP. This study presents the findings of 17 patients (nine males and eight females, aged 34 to 71 years; mean age: 54 years) that were compared in a split-mouth design and followed for 3 months. To the best of the authors' knowledge, this is the first reported case series using a CO₂ laser for de-epithelialization in combination with SRP for the treatment of CP.

CONCLUSION

Sites treated with the CO₂ laser tended to show a greater decrease in probing depths, greater amounts of recession, and greater gains in clinical attachment levels, but the results were not statistically significantly better than SRP alone.

A comparative analysis of demographic and academic success characteristics of on-line and on-campus RN-to-BSN students

Despite their proliferation, little is known about how registered nurse-to-bachelor of science in nursing (RN-to-BSN) students enrolled in on-line programs compare to those in on-campus programs. This article reports on a comparative analysis of 3,802 students (332 on-campus, 3,470 on-line) conducted to better understand characteristics and educational outcomes of individuals who select on-line learning options. Programs were compared for student demographic characteristics (gender, race, age, and prior degree status) and outcome variables (progression to graduation and time to completion). Students in the on-line program were significantly older than on-campus students, and significantly more Caucasian/White students were in the on-line program. There were no significant differences in gender between groups. Among only those students who had already graduated, on-campus students took significantly less time to graduate than on-line students and had a higher graduation rate. However, the rate of program discontinuation was similar in both groups, and most on-line students who had not graduated were still progressing in the program. Implications of these findings are that students enrolled in an on-line RN-to-BSN program specifically designed to provide them with flexible 5-week terms and substantive student supports can have similar educational outcomes.

Clinical, angiographic, and procedural predictors of periprocedural complications during chronic total occlusion percutaneous coronary intervention

OBJECTIVES

To identify clinical, angiographic, and procedural factors associated with increased risk of periprocedural complications during chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

BACKGROUND

Successful CTO PCI can provide significant clinical benefit; however, procedural risks have received limited study. We sought to identify factors associated with increased CTO PCI periprocedural risk that could be utilized to guide patient and lesion selection.

METHODS

The clinical, angiographic, and procedural records of 336 consecutive CTO PCI procedures performed at a single center from May 2005 through 2012 were reviewed, and data on periprocedural complications were recorded. Logistic regression was performed to identify independent predictors of periprocedural complications during CTO PCI.

RESULTS

The incidence of major and minor complications was 3.9% and 10.4%, respectively. Minor bleeding and vascular events were the most common complications (4.8%), followed by perforation (2.4%), contrast-induced nephropathy (1.8%), and transient hypotension (0.6%). Major complications were uncommon: death (0.3%); emergency coronary artery bypass grafting (0.6%); stroke (0.3%); tamponade (0.3%); clinical myocardial infarction (0.9%); donor vessel injury (0.6%); and major bleeding or vascular events (0.9%). Patients who experienced any complication had higher preprocedure troponin levels and were more likely to undergo treatment using the retrograde approach. In multivariable analysis, use of the retrograde approach was independently associated with increased risk of periprocedural complications (odds ratio, 2.057; 95% confidence interval, 1.045-4.051; P=.04).

CONCLUSIONS

Major complications of CTO PCI are infrequent, but are more common with use of the retrograde approach.

An EGFR wild type-EGFRvIII-HB-EGF feed-forward loop regulates the activation of EGFRvIII

EGFRvIII is a key oncogene in glioblastoma (GBM). EGFRvIII results from an in-frame deletion in the extracellular domain of EGFR, does not bind ligand and is thought to be constitutively active. Although EGFRvIII dimerization is known to activate EGFRvIII, the factors that drive EGFRvIII dimerization and activation are not well understood. Here we present a new model of EGFRvIII activation and propose that oncogenic activation of EGFRvIII in glioma cells is driven by co-expressed activated EGFR wild type (EGFRwt). Increasing EGFRwt leads to a striking increase in EGFRvIII tyrosine phosphorylation and activation while silencing EGFRwt inhibits EGFRvIII activation. Both the dimerization arm and the kinase activity of EGFRwt are required for EGFRvIII activation. EGFRwt activates EGFRvIII by facilitating EGFRvIII dimerization. We have previously identified HB-EGF, a ligand for EGFRwt, as a gene induced specifically by EGFRvIII. In this study, we show that HB-EGF is induced by EGFRvIII only when EGFRwt is present. Remarkably, altering HB-EGF recapitulates the effect of EGFRwt on EGFRvIII activation. Thus, increasing HB-EGF leads to a striking increase in EGFRvIII tyrosine phosphorylation while silencing HB-EGF attenuates EGFRvIII phosphorylation, suggesting that an EGFRvIII-HB-EGF-EGFRwt feed-forward loop regulates EGFRvIII activation. Silencing EGFRwt or HB-EGF leads to a striking inhibition of EGFRvIII-induced tumorigenicity, while increasing EGFRwt or HB-EGF levels resulted in accelerated EGFRvIII-mediated oncogenicity in an orthotopic mouse model. Furthermore, we demonstrate the existence of this loop in human GBM. Thus, our data demonstrate that oncogenic activation of EGFRvIII in GBM is likely maintained by a continuous EGFRwt-EGFRvIII-HB-EGF loop, potentially an attractive target for therapeutic intervention.

Comparison of Minimally Invasive and Conventional Flap Surgery for Treatment of Intrabony Periodontal Defects: A Pilot Case Controlled Study

The purpose of this study was to compare the clinical outcome of conventional flap surgery and minimally invasive surgery for the regenerative treatment of periodontal intrabony defects in a prospective, case-controlled study design. For this purpose, nine healthy individuals with 15 periodontal intrabony defects were included in the study. Patients were randomly assigned to undergo either minimally invasive surgery or conventional flap surgery for treatment of their intrabony periodontal defect. Each patient had preoperative and postoperative X-ray and measurement of periodontal parameters by a blinded examiner. All bony defects were treated with allograft consisting of enamel matrix derivative and demineralized freeze-dried bone. Results of this study indicated that both minimally invasive and conventional flap surgery improved pocket depth and clinical attachment levels after 6 months of surgery with no significant difference between the two surgeries. The overall result of our study suggests that minimally invasive surgery is as effective as conventional flap surgery in the treatment of intrabony periodontal defects and that both techniques appear to provide a comparable outcome.

How to cite this article

Steffer MR, Harrel SK, Rossmann JA, Kerns DG, Rivera-Hidalgo F, Abraham CM, Al-Hashimi I, Solomon ES, Cipher DJ. Comparison of Minimally Invasive and Conventional Flap Surgery for Treatment of Intrabony Periodontal Defects: A Pilot Case Controlled Study. J Contemp Dent 2013;3(2):61-67.

Effectiveness of supported employment for veterans with spinal cord injuries: results from a randomized multisite study

OBJECTIVE

To examine whether supported employment (SE) is more effective than treatment as usual (TAU) in returning veterans to competitive employment after spinal cord injury (SCI).

DESIGN

Prospective, randomized, controlled, multisite trial of SE versus TAU for vocational issues with 12 months of follow-up data.

SETTING

SCI centers in the Veterans Health Administration.

PARTICIPANTS

Subjects (N=201) were enrolled and completed baseline interviews. In interventional sites, subjects were randomly assigned to the SE condition (n=81) or the TAU condition (treatment as usual-interventional site [TAU-IS], n=76). In observational sites where the SE program was not available, 44 subjects were enrolled in a nonrandomized TAU condition (treatment as usual-observational site [TAU-OS]).

INTERVENTIONS

The intervention consisted of an SE vocational rehabilitation program called the Spinal Cord Injury Vocational Integration Program, which adhered as closely as possible to principles of SE as developed and described in the individual placement and support model of SE for persons with mental illness.

MAIN OUTCOME MEASURES

The primary study outcome measurement was competitive employment in the community.

RESULTS

Subjects in the SE group were 2.5 times more likely than the TAU-IS group and 11.4 times more likely than the TAU-OS group to obtain competitive employment.

CONCLUSIONS

To the best of our knowledge, this is the first and only controlled study of a specific vocational rehabilitation program to report improved employment outcomes for persons with SCI. SE, a well-prescribed method of integrated vocational care, was superior to usual practices in improving employment outcomes for veterans with SCI.

Trends in Hospice Referral and Length of Stay at a Veterans Hospital Over the Past Decade

Introduction:

Hospice decreases the fear of dying alone, reduces the agony of death, and helps in maintaining dignity at the end of life. Physicians are encouraged to offer hospice to terminally ill patients early on in their end-of-life care to maximize these benefits. However, there is limited data on the changes and characteristics of hospice utilization. We performed a study to determine the changes in the hospice utilization over the last decade in our hospital.

Methods:

A chart review of all veterans referred to hospice during the years 2001 and 2010 was performed and subsequently analyzed. Analyses were performed with SPSS 19.0 for Windows.

Results:

Referral to hospice increased significantly but the duration of stay did not change in 2010 in comparison with 2001. Factors associated with increased length of stay were full-code status, receiving hospice at home, hospitalization during enrollment in hospice, referral to hospice by oncologist, and a diagnosis of cancer.

Conclusion:

Hospice referrals need to be considered earlier in their disease process for terminally ill patients. In addition, requirement of a do-not-resuscitate order as a condition for hospice at some agencies needs to be revisited, and patients should not be discouraged to seek treatment for reversible medical conditions even when enrolled in hospice.

A comparative study of root defect coverage using an acellular dermal matrix with and without a recombinant human platelet-derived growth factor

BACKGROUND

The objective of this case series is to compare root defect coverage results and healing responses of bilateral recession defects treated with acellular dermal matrix (ADM) with and without recombinant human platelet-derived growth factor (rhPDGF).

METHODS

Seventeen patients with 40 bilateral gingival recession defects were compared. Each defect was ≥2 mm and treated with ADM and a coronally advanced flap. Using split-mouth design, the control-side ADM was hydrated in sterile saline, whereas the test-side ADM was hydrated in rhPDGF. The patients were evaluated at 1 week, 1 month, 3 months, and 6 months. Standardized measurements were taken preoperatively at 3 and 6 months. Healing was clinically assessed at 1 week and 1 month post-surgically.

RESULTS

Both test and control groups showed significant gain in root defect coverage over the 6-month period for all individuals, with the test group showing a 69.0% gain and the control group showing a 76.7% gain. Patients divided into Miller Class I and Class III defects were also found to have a significant gain in root defect coverage over 6 months. The test group showed 84.1% gain, and the control group showed 84.7% gain for Miller Class I defects. For Miller Class III defects, the test group showed 51.5% gain, and the control group showed a 60.8% gain. One week after surgery, 35% of the test group showed better healing, whereas 15% of the control group showed better healing. One month after surgery, 20% of the test group showed better healing, whereas 15% of the control group showed better healing.

CONCLUSION

Based on the results of this case series, there were no statistically or clinically significant differences in root defect coverage, keratinized tissue, clinical attachment level, or clinical healing for treatment of root recession with a coronally advanced flap and ADM with and without rhPDGF.

Methods of a multisite randomized clinical trial of supported employment among veterans with spinal cord injury

This article compares the methods of a randomized multisite clinical trial of evidence-based supported employment with conventional vocational rehabilitation among veterans with spinal cord injury (SCI). The primary hypothesis is that, compared with conventional vocational rehabilitation (i.e., standard care), evidence-based supported employment will significantly improve competitive employment outcomes and general rehabilitation outcomes. The secondary hypothesis is that evidence-based supported employment in SCI will be more cost-effective than standard care. The current article describes the clinical trial and presents baseline data. The present sample includes 301 veterans with SCI, which includes paraplegia (50%), high tetraplegia (32%), and low tetraplegia (18%). Baseline data indicate that 65% of this sample of employment-seeking veterans with SCI had never been employed postinjury, despite the fact that nearly half (41%) had received some type of prior vocational rehabilitation. These rates of unemployment for veterans with SCI are consistent with the rates reported for community samples of persons with SCI. Forthcoming outcome data will provide much needed insights into the best practices for helping these veterans restore vocational goals and improve overall quality of life.

High rates of stopping or switching biological medications in veterans with rheumatoid arthritis

OBJECTIVES

To define the characteristics of a population of veterans with rheumatoid arthritis (RA) who have stopped or switched their first biologic agent, and to assess if measures of disease activity are predictors in the decision to alter the regimen.

METHODS

A retrospective analysis of the VA electronic medical record system identified RA patient demographic and disease activity parameters from 1999 to 2007. Demographic data included age, race/ethnicity, sex, and tobacco use. Disease-specific data included date of RA onset, past DMARD therapies, prednisone use, as well as the disease activity score (DAS-28) and the health assessment questionnaire (HAQ) at each clinic visit. The use of six biologicals (infliximab, etanercept, adalimumab, abatacept, rituximab, anakinra) was identified in order to compare those who continued with the medication to those discontinuing or switching to another biological. Descriptive and parametric statistics were applied to define differences between the two groups.

RESULTS

Of 454 RA patients identified, 212 have been on a biologic agent at one point in time, and 100 patients (47%) had either stopped or switched their first biologic agent. Among these 100 patients, the most common reasons for stopping or switching a biologic agent were adverse events (in 48%) and inefficacy (43%) Adverse events included malignancies (23% of 48 patients), rash (23%), infections (18.8%), and cardiac complications (18.8%). When comparing the 100 patients versus the 112 that did not stop or switch their first agent, the DAS-28 correlated significantly with a change of regimen with an OR 2.1 (p<0.001). The HAQ score had an OR of 2.0 (p<0.04).

CONCLUSION

RA patients who continue taking their initial biologic medication have similar age, RA disease duration, ethnicity, and smoking status to those requiring switching or discontinuation. The DAS28 and HAQ scores significantly correlated with stopping or switching of a first biologic agent. Adverse event rates were high and their distributions differed in this population compared to previous studies of younger Caucasian females.