Preferences and Demand for Mosquito Control among Dengue-Endemic Communities in Peñuelas, Puerto Rico: An Application of the Best-Worst Choice Model

Aedes aegypti is the primary vector of dengue virus and threatens 3.9 billion people living in many tropical and subtropical countries. Prevention and reduction of dengue and other Aedes-borne viruses, including Zika and chikungunya, requires control of mosquito populations. Community mobilization and input are essential components of vector control efforts. Many vector control campaigns do not engage communities prior to implementation, leading to program failure. Those that do often conduct basic knowledge, attitude, and practice surveys that are not designed to explicitly elicit preferences. Here, we applied a novel stated preference elicitation tool, best-worst choice, to understand preferences, willingness to participate, and willingness to pay for mosquito control in dengue-endemic communities of Peñuelas, Puerto Rico. Findings revealed that the community preferred mosquito control programs that are 1) applied at the neighborhood level, 2) implemented by the local government, and 3) focused specifically on reducing disease transmission (e.g., dengue) instead of mosquito nuisance. Programs targeting the reduction of disease transmission and higher educational level of participants increased willingness to participate. Participants were willing to pay an average of $72 annually to have a program targeting the reduction of diseases such as dengue. This study serves as a model to engage communities in the design of mosquito control programs and improve stakeholders' decision-making.

Surgeon reported treatment choices for AO type B and C thoracolumbar fractures without neurological deficits: An expert survey

INTRODUCTION

Less invasive spine surgery (LISS) has become well-established for thoracolumbar burst fractures without neurological deficits. However, notable controversy persists regarding the adequacy of LISS for more unstable AO type B and C injuries, as it does not allow for formal open fusion.

MATERIALS AND METHODS

In this cross-sectional survey experienced spine surgeons of the Dutch Spine Society were invited to participate (56 participants). They were asked to indicate the most appropriate treatment for AO type B1, B2 (L1: A1 and L1: A3), B3 and C (L1: A4) injuries at level Th12-L1. Taking into account: age, AO N0-N1, or polytrauma. Specific agreement between participants was obtained applying Variation Ratio (VR).

RESULTS

A significant level of overall agreement was observed for AO type-B1 injuries with 73.8% of participants opting for percutaneous short-segment fixation (VR 0.775). For AO type-B3 injuries, 79.4% of participants favored percutaneous long-segment fixation (VR 0.794). for AO type-B2 injuries, there was less overall agreement (VR 0.571-0.657). Nonetheless, when considering all AO type-B injuries combined, percutaneous fixation emerged as the most preferred treatment option with substantial agreement (VR 0.871-0.923). Conversely, for AO type-C injuries, there was less agreement among the participants (VI 0.411), 26.5% of them chose additional open spinal fusion.

CONCLUSION

For all AO type-B injuries there was substantial agreement to treat these fractures with percutaneous techniques. For AO type-C injuries, the survey results do not support a consensus. Nevertheless, the responses raise important questions about the necessity of spinal fusion for such injuries.

Synergic versus Antagonist Effects of Rutin on Gallic Acid or Coumarin Incorporated into Chitosan Active Films: Impacts on Their Release Kinetics and Antioxidant Activity

This work deals with the study of the release and antioxidant activity kinetics of three natural antioxidants associated as binary mixture (coumarin, and/or gallic acid and rutin) from chitosan films. Antioxidants were incorporated into film alone or in binary mixture. The aim was to determine the influence of rutin on the phenolic acid and benzopyrone. The UV-visible light transmission spectra of the films were also investigated. Neat chitosan films and chitosan incorporated coumarin exhibited high transmittance in the UV-visible light range, while GA-added chitosan films showed excellent UV light barrier properties. The molecular interactions between chitosan network and antioxidants were confirmed by FTIR where spectra displayed a shift of the amide-III peak. Rutin has a complex structure that can undergo ionization. The chitosan network structure induced change was found to influence the release behavior. The film containing rutin showed the highest antioxidant activity (65.58 ± 0.26%), followed by gallic acid (44.82 ± 3.73%), while coumarin displayed the lowest activity (27.27 ± 4.04%). The kinetic rate against DPPH-free radical of rutin is three times higher than coumarin. The kinetic rates were influenced by the structure and interactions of the antioxidants with chitosan. Rutin exhibited a slow release due to its molecular interactions with chitosan, while coumarin and gallic acid showed faster release. The diffusion coefficient of coumarin is 900 times higher than that of rutin. The rutin presence significantly delayed the release of the gallic acid and coumarin, suggesting an antagonistic effect. However, their presence weakly affects the release behavior of rutin.

Biallelic variants in COQ7 cause distal hereditary motor neuropathy with upper motor neuron signs

COQ7 encodes a hydroxylase responsible for the penultimate step of coenzyme Q10 (CoQ10) biosynthesis in mitochondria. CoQ10 is essential for multiple cellular functions, including mitochondrial oxidative phosphorylation, lipid metabolism, and reactive oxygen species homeostasis. Mutations in COQ7 have been previously associated with primary CoQ10 deficiency, a clinically heterogeneous multisystemic mitochondrial disorder. We identified COQ7 biallelic variants in nine families diagnosed with distal hereditary motor neuropathy with upper neuron involvement, expending the clinical phenotype associated with defects in this gene. A recurrent p.Met1? change was identified in five families from Brazil with evidence of a founder effect. Fibroblasts isolated from patients revealed a substantial depletion of COQ7 protein levels, indicating protein instability leading to loss of enzyme function. High-performance liquid chromatography assay showed that fibroblasts from patients had reduced levels of CoQ10, and abnormal accumulation of the biosynthetic precursor DMQ10. Accordingly, fibroblasts from patients displayed significantly decreased oxygen consumption rates in patients, suggesting mitochondrial respiration deficiency. Induced pluripotent stem cell-derived motor neurons from patient fibroblasts showed significantly increased levels of extracellular neurofilament light protein, indicating axonal degeneration. Our findings indicate a molecular pathway involving CoQ10 biosynthesis deficiency and mitochondrial dysfunction in patients with distal hereditary motor neuropathy. Further studies will be important to evaluate the potential benefits of CoQ10 supplementation in the clinical outcome of the disease.

Community Engaged Translation of Adverse Childhood Experiences Information Into Locally Relevant Public Health Messaging

Objective: Conduct Boot Camp Translation to develop locally relevant messages about Adverse Childhood Experiences. Setting: The Oxford Hills region of Maine is home to Stephen's Memorial Hospital, which funds Healthy Oxford Hills, a coalition dedicated to promoting a caring, self-reliant, and healthy community. Residents of Oxford Hills bare a disproportionate burden of poverty, low income, chronic disease and ACEs as compared to other counties in Maine. The Community Engaged Research Council identified this topic as a priority issue for the community and jointly secured funding. Study Design: BCT brings community members, clinicians and researchers together in a systematic and structured way. Participants share their personal expertise and knowledge of their communities to develop locally relevant health messages. 17 individuals with a broad array of lived experience participated. During 2021, meetings included educational sessions on ACEs, Stigma in Healthcare, Research Ethics, and local partners work in this area. The group met regularly to develop a shared understand of ACEs, how their community is impacted and to craft messages. The study team conducted a program evaluation. Intervention: The group developed 4 messages; 3 target everyone in the community and one targets parents and caregivers. The messages are as follows (1) Hard things happen, but these things do not define us (2) Make a connection; resilience starts by reaching out (3) Connecting helps us rebuild; one positive relationship can make a difference (4) Love. Support. Connect. Messages were produced on yard signs, Facebook profile picture, storefront windows, business cards, a placemat and were distributed throughout the region. Measures: Process measures included participant experience and overall impressions of the BCT. Data collection included observations using the Pyramid of Engagement Rubric, participant surveys and interviews. Additional descriptive measures included number of materials created, distribution locations and the use of QR codes mapped to a partner website and social media hashtags to assess engagement. Results: 100% of respondents found the BCT process valuable and thought the right mix of people were involved. 44% of participants were not able to participate at much as they would have liked due to issues with technology and scheduling. 75% of initial participants completed the project.

Risk factors associated with under-five stunting, wasting, and underweight in four provinces of the Democratic Republic of Congo: analysis of the ASSP project baseline data

BACKGROUND

Determining the magnitude and risk factors of undernutrition in a country that has one of the highest prevalence of undernutrition in the world is paramount for developing contextual interventions.

METHODS

This study used baseline data from the ASSP project to estimate prevalence of stunting, wasting, and underweight in four provinces of DRC. It involved 3911 children aged 0-59 months old and mother pairs. Height-for-age Z scores, Weight-for-height Z scores, and Weight-for-age Z scores were calculated and used to classify child stunting, wasting and underweight respectively, based on the 2006 World Health Organization (WHO) growth reference. Hierarchical logistic regressions were used to identify risk factors associated with stunting, wasting and underweight. All analyses were conducted using STATA 15.1, and statistical significance was set at p < 0.05.

RESULTS

The prevalence of stunting, underweight and wasting was 42.7%, 21.9% and 8.2% respectively. Increasing child's age was a risk factor associated with stunting and underweight, while sex was not associated with the 3 indicators of undernutrition. Low levels of mother's education, mothers working in the last 12 months prior to the survey, children living in the province of Kasai occidental, children born at a health facility, children perceived by their mothers to be born very small were associated with higher risks of stunting. Factors associated with underweight were children from the province of Kasai occidental, mothers who worked in the last 12 months prior to the survey, and children perceived to be born very small or small by their mothers. Children born to mothers aged 35-49 years and children breastfed in combination with drinking water were at higher risk of wasting.

CONCLUSION

Prevalence of undernutrition in DRC is high. This study has identified certain modifiable risk factors associated with stunting, wasting and underweight. To reduce the burden of undernutrition in DRC, authorities should target factors at individual and community levels by improving women's education, child feeding practices and promoting agriculture.

The impact of the COVID-19 pandemic on healthcare access and utilisation in South Sudan: a cross-sectional mixed methods study

BACKGROUND

Indirect effects of the COVID-19 pandemic on communities in fragile and conflict-affected settings may be severe due to reduced access and use of healthcare, as happened during the 2015 Ebola Virus Disease outbreak. Achieving a balance between short-term emergency response and addressing long-term health needs is particularly challenging in fragile and conflict-affected settings such as South Sudan, given the already significant barriers to accessing healthcare for the population. This study sought to characterise the effect of COVID-19 on healthcare access and South Sudan's healthcare response. This can inform efforts to mitigate the potential impacts of COVID-19 or other epidemiological threats, and contribute to understanding how these may be balanced for greater health system resilience in fragile contexts.

METHODS

We conducted a mixed methods study in three of South Sudan's states, combining data from a cross-sectional quantitative household survey with qualitative interviews and Focus Group Discussions.

RESULTS

Even though some fears related to COVID-19 were reported, we found these did not greatly dissuade people from seeking care and do not yield significant consequences for health system programming in South Sudan. The pillars of the response focused on risk communication and community engagement were effective in reaching communities through different channels. Respondents and participants reported behaviour changes that were in line with public health advice. We also found that the implementation of COVID-19 response activities sometimes created frictions between the national government and international health actors, and that COVID-19 caused a greater reliance on, and increased responsibility for, international donors for health planning.

CONCLUSIONS

Given the fact that global priorities on COVID-19 are greatly shifting, power dynamics between international health agencies and the national government may be useful to consider in further COVID-19 planning, particularly for the vaccine roll-out. South Sudan must now navigate a period of transition where COVID-19 vaccine roll-out continues and other domestic health burdens are re-prioritised.

Cardiopulmonary Resuscitation Training in Select Rhode Island High Schools: A Descriptive Study

Fewer than 15% of people who have out-of-hospital cardiac arrests survive, but chances of survival can be tripled with effective bystander cardiopulmonary resuscitation (CPR). The majority of states, including Rhode Island, require high school CPR training, yet the impact of this is not well studied. A 33-question REDCap survey regarding cardiac arrest preparedness, CPR education, and barriers to CPR training was emailed to high school staff in Rhode Island. There were 62 responses; 26% reported their school taught CPR and 94% felt it was important for students to have CPR certification. Barriers included time (85%), budget (82%), and materials (79%). Over 80% felt students would not be able to perform high-quality CPR or properly use a defibrillator. Despite laws requiring CPR training and the belief by school staff of the importance of CPR training, the majority of students are not receiving CPR training. Staff report students do not have the ability to perform effective CPR or use a defibrillator.

977 Breaking Out of Tradition: Designing Escape Rooms as Novel Simulation

Aim

The emerging field of gamification, the addition of game play elements to non-game settings, is widely used in business and is increasingly being used in education. Successful methods have included live leader boards and a web-based game solving a protein folding conundrum.

Method

We designed an escape room (ER), incorporating gaming elements, focussing on communication in a surgical environment. A cross over study was delivered to 4th year medical students, comparing traditional simulation. The ER included logic puzzles, hidden clues, padlocked boxes, and surgical skills appropriate to their level. Self-reported engagement and teamwork were recorded, as was observed teamwork and communication skills.

Results

Self-reported engagement was very high for the students compared to more traditional simulation, including better understanding of effective communication strategies. The ER group were less likely to self-identify learning points but structured debrief mitigated this difference.

Conclusions

Gamification techniques can be integrated with good engagement and educational outcomes and should be considered as an adjunct to existing simulation strategy.

971 Gamification of Education; Can Playable Education Result in Better Learning Outcomes?

Aim

Combining traditional simulation (TS) and the emerging field of gamification, to create medical Escape Rooms (ERS) has been used in Nursing to good results but is yet to be widely adopted in medical education. We conducted a pilot study to create ERS for undergraduates to assess their educational value.

Method

Existing Simulation themes of sepsis, post-operative bleeding, trauma, burns and communication in the theatre environment were developed into Escape Rooms by a multidisciplinary team. A cross over study for 4th year students was carried out. Questionnaires were used to evaluate the experience, learning assessed by pre and post quiz and observational tools for teamwork, communication and leadership were utilised.

Results

Qualitative data demonstrated overall good feedback on enjoyment an engagement. Quantitative data collected as pre- and post-exposure learning demonstrated equivocal benefit. Self-assessed teamwork showed equal in all domains and improved in contribution of knowledge and maintaining team focus on the ER group.

Conclusions

Participants find ER enjoyable have similar educational benefits of traditional simulation with the benefits on enhancing non-technical skills amongst a novice group. Escape rooms may be useful as an adjunct to TS particularly at developing non-technical skills.

Resistance to local anaesthetics administered via epidural, intrathecal and pudendal injections

A primigravida presented to our institution in established labour. Her past medical history included joint hypermobility, postural orthostatic tachycardia syndrome, Raynaud's syndrome, fibromyalgia and gastroparesis. Two technically uneventful lumbar epidurals with bupivacaine and fentanyl provided no analgesia. The spinal element of a planned combined spinal and epidural was also ineffective, so alternative analgesia was offered. While this was being prepared, the obstetric team recommended an instrumental delivery. An attempted pudendal nerve block with lidocaine had no effect, and general anaesthesia was therefore provided for a lower segment caesarean delivery. We believe this is the first report of local anaesthetic resistance via three distinct routes of administration in a single patient. Resistance to local anaesthetics is unusual and is more common in patients with hypermobility spectrum disorders. This case demonstrates the unique experience of a patient with a hypermobility condition who had failed epidural, spinal and pudendal local anaesthetic. We suggest that patients with a hypermobility condition should be specifically assessed for local anaesthetic resistance as part of anaesthetic pre-assessment, to enable early planning.

A framework for mapping and monitoring human-ocean interactions in near real-time during COVID-19 and beyond

The human response to the COVID-19 pandemic set in motion an unprecedented shift in human activity with unknown long-term effects. The impacts in marine systems are expected to be highly dynamic at local and global scales. However, in comparison to terrestrial ecosystems, we are not well-prepared to document these changes in marine and coastal environments. The problems are two-fold: 1) manual and siloed data collection and processing, and 2) reliance on marine professionals for observation and analysis. These problems are relevant beyond the pandemic and are a barrier to understanding rapidly evolving blue economies, the impacts of climate change, and the many other changes our modern-day oceans are undergoing. The "Our Ocean in COVID-19″ project, which aims to track human-ocean interactions throughout the pandemic, uses the new eOceans platform (eOceans.app) to overcome these barriers. Working at local scales, a global network of ocean scientists and citizen scientists are collaborating to monitor the ocean in near real-time. The purpose of this paper is to bring this project to the attention of the marine conservation community, researchers, and the public wanting to track changes in their area. As our team continues to grow, this project will provide important baselines and temporal patterns for ocean conservation, policy, and innovation as society transitions towards a new normal. It may also provide a proof-of-concept for real-time, collaborative ocean monitoring that breaks down silos between academia, government, and at-sea stakeholders to create a stronger and more democratic blue economy with communities more resilient to ocean and global change.

In cold blood: Observational descriptive review of Eastern Massasauga rattlesnake bites reported to a single poison center over time

The Eastern Massasauga rattlesnake (Sistrurus catenatus catenatus) is a pit viper indigenous to the Great Lakes region and the only venomous snake native to Michigan. It is small-to-medium, thick-bodied with dark brown, bow-tie shaped blotches. Its behavior is described as reclusive and docile and it prefers damp habitats. The venom of the Eastern Massasauga is primarily cytotoxic and hemotoxic. Previous literature describes severe coagulopathies following Eastern Massasauga envenomings, with some resulting in death. The objective of this study was to characterize Eastern Massasauga envenomings in humans reported to the Michigan Poison & Drug Information Center from 2003 to 2020, including a description of clinical manifestations, incidence and characterization of coagulopathies, and medical outcome severities. This was a retrospective review of Eastern Massasauga snakebites reported to our state poison center over time. Coagulopathies were classified according to previous toxicological snakebite literature. The degree of envenoming was scored using an institutional guideline, representing a modified version of validated snakebite severity score system. Our longitudinal review demonstrated Eastern Massasauga bites led to clinically significant toxicity, including persistent, recurrent, and late coagulopathies, though with low incidence of bleeding events. Cases typically resolved with use of antivenom. This, to our knowledge, is the largest descriptive case series characterizing Eastern Massasauga snakebites.

Hispanic Ethnicity and Cervical Cancer Precursors Among Low-Income Women in Arizona

Purpose

In the United States, Hispanics are more likely to be diagnosed with cervical cancer compared to Non-Hispanic Whites. Annually, 250,000 to 1 million women are diagnosed with a precursor to CC. The aim of this study was to assess whether Hispanics have a higher prevalence of cervical dysplasia compared to Non-Hispanics Whites among a population of low-income women.

Patients and Methods

We analyzed the results of 10,911 cervical cytology tests administered between 2003 and 2016 that were funded through the Center for Disease Control and Prevention’s (CDC) program for low-income, uninsured women entitled the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). In the state of Arizona, the program is called the Well Women HealthCheck Program (WWHP). Logistic regression was used to identify increased risk of dysplasia, including low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL/ICC), and multinomial logistic regression was used to assess increased likelihood for LSIL and HSIL/ICC as separate categories.

Results

In the crude analysis, Hispanic ethnicity was modestly associated with higher prevalence of LSIL (odds ratio (OR)=1.39, 95% CI=1.01–1.91), but this association was not statistically significant after adjusting for confounders. However, in the final models, lower income was independently associated with LSIL (adjusted odds ratio [aOR]=1.55, 95% CI=1.30–1.44), while smoking (aOR=2.88, 95% CI=1.21–6.84) and no history of Pap test within five years (aOR=3.54, 95% CI=1.61–6.99) were independently associated with HSIL.

Conclusion

After adjusting for confounding in a sample of low-income women with comparable Pap screening rates, ethnicity was not associated with greater prevalence of abnormal pap smears. However, other variables were independently associated with LSIL and HSIL. The higher proportion of LSIL cases among lower income individuals compared to those with higher incomes, and the higher proportion of HSIL cases observed among those screened least regularly stresses the importance of programs like WWHP: programs that target low-income, uninsured women. These programs help save lives.

Maintaining procedural skills for academic emergency medicine faculty: A needs assessment

BACKGROUND

Emergency physicians require competence performing critical and routine procedures. The clinical practice of emergency medicine (EM) alone may be insufficient for the acquisition and maintenance of skills. Prior studies suggest the presence of trainees in academic settings and/or the low frequency of procedures increase the risk of skills attrition among faculty. We sought to develop a valid needs assessment survey to inform a faculty procedural skills (FPS) maintenance curriculum.

METHODS

A Web-based FPS survey was designed to assess experiences performing procedures, self-reported confidence with procedures, and learning preferences for skills maintenance. The survey was administered at a large academic department of EM. Responses were analyzed to determine survey construct validity, faculty attitudes about procedural attrition, and preferred learning methods.

RESULTS

Among EM faculty, confidence was significantly higher for common versus uncommon procedures (p < 0.001). EM faculty respondents reported significantly greater confidence than pediatric EM (PEM) faculty for both common adult procedures (EM mean = 3.7 [±0.3], PEM = 3.0 [±0.4], p < 0.001), and uncommon adult procedures (EM = 2.7 [±0.4], PEM = 2.1 [±0.5], p < 0.001). PEM faculty reported significantly greater confidence with pediatric procedures than EM faculty (PEM mean [±SD] = 3.5 [±0.8], EM = 2.2 [±0.8], p < 0.001). Nearly all faculty (93% [52/56]) agreed that procedural attrition is a concerning problem, and 80% (44/56) had personally experienced it. The most preferred learning methods were task trainers and simulation. Faculty preferred learning environments with faculty peers (91%) over mixed groups with trainees (50%).

CONCLUSIONS

Significant differences in procedural skills confidence between common and uncommon procedures, and between EM and PEM faculty, indicate that the FPS survey displayed appropriate construct validity. The finding that skills attrition is prevalent among EM and PEM faculty highlights the need for skill maintenance programming, preferably in peer groups employing task trainers and simulation.

Puff-resolved analysis and selected quantification of chemicals in the gas phase of E-Cigarettes, Heat-not-Burn devices and conventional cigarettes using single photon ionization time-of-flight mass spectrometry (SPI-TOFMS): A comparative study

INTRODUCTION

A wide array of alternative nicotine delivery devices (ANDD) has been developed and they are often described as less harmful than combustible cigarettes. This work compares the chemical emissions of three ANDD in comparison to cigarette smoke. All the tested ANDD are characterized by not involving combustion of tobacco.

METHOD

Single photon ionization time-of-flight mass spectrometry (SPI-TOFMS) is coupled to a linear smoking machine, which allows a comprehensive, online analysis of the gaseous phase of the ANDD aerosol and the conventional cigarette smoke (CC). The following devices were investigated in this study: a tobacco cigarette with a glowing piece of coal as a heating source, an electric device for heating tobacco and a first-generation electronic cigarette. Data obtained from a standard 2R4F research cigarette are taken as a reference.

RESULTS

The puff-by-puff profile of all products was recorded. The ANDD show a substantial reduction or complete absence of known harmful and potentially harmful substances compared to the CC. In addition, tar substances (i.e. semivolatile and low volatile aromatic and phenolic compounds) are formed to a much lower extent. Nicotine, however, is supplied in comparable amounts except for the investigated electronic cigarette.

CONCLUSIONS

The data shows that consumers switching from CC to ANDD are exposed to lower concentrations of harmful and potentially harmful substances. However, toxicological and epidemiological studies must deliver conclusive results if these reduced exposures are beneficial for users.

IMPLICATION

The comparison of puff-resolved profiles of emissions from different tobacco products, traditional and alternative, may help users switch to lower emission products. Puff-resolved comparison overcomes technical changes, use modes between products and may help in their regulation.

Social Isolation, Health, and Health Care: Perspectives Among Older Adults Residing in Public Housing

By 2035, U.S. adults > 65 will outnumber children. The growing lack of affordable housing combined with fixed incomes will lead to more older adults residing in public housing. Public housing authorities, in turn, will face growing health and social needs among their residents. In partnership with a local housing authority, we conducted a qualitative study to better understand the health and social needs of older adult public housing residents. We conducted semi-structured qualitative interviews with 27 older adults at two public housing sites in Austin, Texas; we asked about their experience of aging in public housing, their health, healthcare, and community life. Interviews were audio-recorded and transcribed; interviews were systematically coded and verified by a second coder. Themes were identified using comparative analysis. We interviewed 16 females and 11 males (mean age = 71.7 years). We identified three themes. Residents characterized good healthcare as that which is provided by physicians who are consistent educators that listen to residents’ primary concerns. They defined health as being mobile and lacking pain. Finally, they desire more, recurring opportunities to learn about health and connect interpersonally within their housing community; they perceive limited meaningful relationships as a significant contributor to poor health among residents. The older adult public housing residents in our study outlined what good health and healthcare looks like. These themes can be utilized to improve relationships between residents and their healthcare providers. Social isolation can be mitigated through public housing programming that promotes physical and mental acuity.

Age at diagnosis of Type 2 diabetes in Germany: a nationwide analysis based on claims data from 69 million people

AIM

For many European countries, including Germany, no valid estimates are available on age at diagnosis of Type 2 diabetes. Thus, we aimed to estimate the age at diagnosis in Germany.

METHODS

Age at diagnosis of Type 2 diabetes in Germany was estimated based on Type 2 diabetes prevalence and incidence and the age distribution of the German population. Age- and sex-specific incidence and prevalence in 2014/2015, based on claims data from statutory health insurance (n= 69 000 000, ~85% of the German population), and the age pyramid for Germany in 2015 were used for the calculation. Age at Type 2 diabetes diagnosis was stratified by sex. CIs were estimated using bootstrap methods. In addition, the age range in which 50% of the population received a diagnosis of Type 2 diabetes was calculated (the interquartile range).

RESULTS

The mean ± sd age at Type 2 diabetes diagnosis in 2015 was 61.0 ± 13.4 years (95% CI 60.9-61.0) in men. Women were diagnosed ~2 years later than men (mean age 63.4 ± 14.9 years; 95% CI 63.4-63.5). The age range in which 50% of the population was diagnosed with diabetes was 53-72 years for men and 54-76 years for women.

CONCLUSIONS

The sex differences are mainly attributable to a higher incidence of Type 2 diabetes in men than women during middle age and the higher absolute number of women in the older ages. The early age at diabetes diagnosis compared to average life expectancy means that the risk of diabetes-related complications is increased.

Sexual dimorphism of physical activity on cognitive aging: Role of immune functioning

OBJECTIVE

Exercise is one of the most potent strategies available to support cognitive health with age, yet substantial variability exists. Sexual dimorphism is evident for brain and immune functioning, the latter being implicated as important pathway for exercise. We examined the moderating role of sex on the relationship between physical activity and systemic inflammatory and brain health outcomes in support of more personalized approaches to behavioral interventions.

METHODS

Our discovery cohort included 45 typically aging women matched on age (±5y) and education (±2y) to 45 men (mean age = 72.5; Clinical Dementia Rating = 0) who completed self-reported current physical activity (Physical Activity Scale for Elderly), blood draw, neuropsychological evaluation, and brain MRI. An independent sample of 45 typically aging women and 36 men who completed the same measures comprised a replication cohort. Plasma was analyzed for 11 proinflammatory cytokine and chemokine markers via MesoScale Discovery.

RESULTS

Discovery cohort: Reported physical activity did not differ between sexes (150 vs. 157, p = 0.72). There was a significant interaction between sex and physical activity on chemokine markers MDC, MIP-1b, MCP-4, and eotaxin-3 (ps < 0.03), with a similar trend for MCP-1 and INFγ (ps < 0.09). Men who reported greater activity demonstrated lower inflammatory markers, an effect attenuated-to-absent in women. An interaction between sex and physical activity was also observed for parahippocampal volumes (p = 0.02) and cognition (processing speed and visual memory; ps < 0.04). Again, the beneficial effect of physical activity on outcomes was present in men, but not women. Replication cohort analyses conferred a consistent effect of sex on the relationship between physical activity and immune markers; models examining neurobehavioral outcomes did not strongly replicate. Across cohorts, post-hoc models demonstrated an interaction between sex and activity-related inflammatory markers on total gray matter volume and visual memory. Men with higher inflammatory markers demonstrated poorer brain structure and function, whereas inflammatory markers did not strongly relate to neurobehavioral outcomes in women.

CONCLUSIONS

Greater physical activity was associated with lower markers of inflammation in clinically normal older men, but not women - an effect consistently replicated across cohorts. Additionally, men appeared disproportionately vulnerable to the adverse effects of peripheral inflammatory markers on brain structure and function compared to women. Immune activation may be a male-specific pathway through which exercise confers neurobehavioral benefit.

Sociodemographic and clinical characteristics associated with vitamin D status in newly diagnosed pediatric cancer patients

Vitamin D deficiency and insufficiency are associated with serious sequelae in childhood cancer survivors. However, data on vitamin D deficiency in children with newly diagnosed cancer are scarce and the role of sociodemographic factors and vitamin D supplementation is largely unknown. We assessed vitamin D status and its socio-demographic and clinical correlates in 163 children with newly diagnosed cancer, using 25-hydroxy vitamin D (25(OH)D) concentrations and assessed longitudinal changes following vitamin D supplementation. Sixty-five percent of the patients with newly diagnosed cancer had low 25(OH)D concentrations. Fifty-two patients (32%) were vitamin D deficient (≤20 ng/mL 25(OH)D concentration), and 53(33%) were insufficient (21-29 ng/mL 25(OH)D concentration). Age over 10 (P = 0.019), Hispanic ethnicity (P = 0.002), and female sex (P = 0.008) were significantly associated with lower 25(OH)D concentration at diagnosis. Vitamin D supplementation resulted in significant increase in 25(OH)D concentrations (P < 0.001). However, following supplementation in the longitudinal analysis, this increase was less pronounced in Hispanic patients vs. non-Hispanic (P = 0.007), and in children with solid tumors vs. hematological malignancies (P = 0.003). Vitamin D deficiency and insufficiency are common in children with newly diagnosed cancer. Hispanic patients, females and older children were at higher risk for vitamin D deficiency and insufficiency. Although supplementation appeared to increase 25(OH)D concentrations over time, this increase was not as pronounced in certain subsets of patients. Prospective trials of the effects of vitamin D supplementation on bone health in children with newly diagnosed cancer are warranted, particularly in Hispanics and patients with solid tumors.

Effects of HIV status on non-metastatic cervical cancer progression among patients in Lusaka, Zambia

INTRODUCTION

Sub-Saharan Africa has the highest global incidence of cervical cancer. Cervical cancer is the most common cause of cancer morbidity and mortality among women in Zambia. HIV increases the risk for cervical cancer and with a national Zambian adult HIV prevalence of 16%, it is important to investigate the impact of HIV on the progression of cervical cancer. We measured differences in cervical cancer progression between HIV-positive and HIV-negative patients in Zambia.

METHODS

This study included 577 stage I and II cervical cancer patients seen between January 2008 and December 2012 at the Cancer Diseases Hospital in Lusaka, Zambia. The inclusion criteria for records during the study period included known HIV status and FIGO stage I and II cervical cancer at initial date of registration in the Cancer Diseases Hospital. Medical records were abstracted for clinical and epidemiological data. Cancer databases were linked to the national HIV database to assess HIV status among cervical cancer patients. Logistic regression examined the association between HIV and progression, which was defined as metastatic or residual tumor after 3 months of initial treatment.

RESULTS

A total of 2451 cervical cancer cases were identified, and after exclusion criteria were performed the final analysis population totaled 537 patients with stage I and II cervical cancer with known HIV status (224 HIV-positive and 313 HIV-negative). HIV-positive women were, on average, 10 years younger than HIV-negative women who had a median age of 42, ranging between 25 and 72. A total of 416 (77.5%) patients received external beam radiation, and only 249 (46.4%) patients received the recommended treatment of chemotherapy, external beam radiation, and brachytherapy. Most patients were stage II (85.7%) and had squamous cell carcinoma (74.7%). HIV-positive patients were more likely to receive lower doses of external beam radiation than HIV-negative patients (47% vs 37%; P<0.05, respectively). The median total dose of external beam radiation for HIV-positive and HIV-negative patients was 46 Gy and 50 Gy, respectively. HIV positivity did not lead to tumor progression (25.4% in HIV-positive vs 23.9% in HIV-negative, OR 1.04, 95% CI [0.57, 1.92]). However, among a subset of HIV-positive patients, longer duration of infection was associated with lower odds of progression.

CONCLUSION

There was no significant impact on non-metastatic cervical cancer progression by HIV status among patients in Lusaka, Zambia. The high prevalence of HIV among cervical cancer patients suggest that HIV-positive patients should be a primary target group for HPV vaccinations, screening, and early detection.

Hepcidin-regulating Iron-metabolism Genes and Pancreatic Ductal Adenocarcinoma: A Pathway Analysis of Genome-wide Association Studies

Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal cancer, and epidemiological studies have suggested positive associations with iron and red meat intake. Rare mutations in genes involved in the hepcidin-regulating pathway are known to cause iron overload and hemochromatosis. We hypothesize that the hepcidin-regulating pathway as characterized by common variants from genome-wide association studies will be associated with PDAC. Methods: We conducted a large pathway-based meta-analysis of the hepcidin-regulating genes using the summary based adaptive rank truncated product (sARTP) method in 9,253 PDAC cases and 12,525 controls of European descent from the Pancreatic Cancer Cohort (PanScan) and the Pancreatic Cancer Case-Control (PANC4) consortia. Our analysis included 11 hepcidin-regulating genes (BMP2, BMP6, FTH1, FTL, HAMP, HFE, HJV, NRF2, SLC40A1, TFR1, TFR2) and adjacent genomic regions (20 kb upstream and downstream) with a total of 412 single-nucleotide polymorphisms (SNPs). We also conducted the sARTP with four iron status biomarkers (serum iron, transferrin, transferrin saturation, and ferritin, n = 23,986) using summary statistics from previous GWAS studies (Benyamin, et al. 2014) to examine if the hepcidin-regulating genes were also associated with these iron traits. The sARTP method combines SNP-level associations across variants in a gene or a pathway. Signals from up to five of the most associated SNPs for each gene studied were accumulated. Results: The hepcidin-regulating pathway was significantly associated with PDAC (P-value = 0.002) with the HJV, TFR2, and TFR1 genes contributing the most to the association (gene level P-values = 0.001, 0.014, and 0.019, respectively). The pathway associations were more significant in women than men. This pathway was also significantly associated with the four biomarkers of iron metabolism (P-values &lt;1.5 × 10–7). Conclusions: Our results support that genetic susceptibility related to the hepcidin-regulating pathway is associated with PDAC and a potential role of iron metabolism in pancreatic carcinogenesis. Further studies are needed to evaluate the modifying effect of iron-rich foods and genetic susceptibility of this pathway and PDAC risk.

Performance of Gem Premier blood gas/electrolyte analyzer evaluated

We evaluated a new analyzer designed for point-of-care testing of blood gases, sodium, potassium, ionized calcium, and hematocrit. The Gem Premier (Mallinckrodt) system has two components: the analyzer and a disposable cartridge. Analysis takes place in the cartridge, which contains the electrochemical sensors, the calibrants, the reagents, the sampling stylus, and the waste container. The system was evaluated for imprecision and accuracy. With aqueous control materials, total imprecision (CV) was: pH, 0.10-0.18%; PCO2, 3.16-5.78%; PO2, 2.92-4.85%; sodium, 0.82-1.44%; potassium, 1.35-1.48%; ionized calcium, 0.75-1.45%; and hematocrit, 1.13-1.83%. Accuracy of the system was assessed by split-sample comparison with the Radiometer ABL 330 blood gas analyzer for pH and blood gases, the Nova Stat Profile 5 for whole-blood electrolyte and hematocrit analysis, and the IL Phoenix for plasma electrolyte analysis. After outlier correction, regression statistics were excellent for all analytes except sodium, which demonstrated Sy[x values between 1.80 and 2.30 mmol/L and 0.85 &lt; or = r &lt; 0.90.

Motivating people to sustain healthy lifestyles using persuasive technology: A pilot study of Korean Americans with prediabetes and type 2 diabetes

OBJECTIVE

To test the efficacy of a hybrid model of the self-help intervention program (hSHIP), which combines a mobile version of SHIP (mSHIP) and personal coaching, to address unique cultural and motivational factors for optimal self-management of type 2 diabetes and prediabetes among Korean Americans (KAs).

METHODS

A single-group feasibility study design was used. The hSHIP utilizes texts and motivational counseling based on well-tested intervention content for KAs. To facilitate the dissemination of hSHIP, we developed a web application adopting the principles of persuasive technology to motivate behavior changes.

RESULTS

Feasibility assessment found that hSHIP was well accepted by both participants and community health workers who delivered the intervention. An average of 1.3% A1C reduction (from 7.8% to 6.5%) was achieved by KAs with diabetes (n = 165), 51.5% of whom lowered their A1C below 6.5% in 6-months. No one with prediabetes (n = 50) progressed to diabetes. Other clinical outcomes (e.g., weight, depression, and blood pressure) also improved significantly; 41.2% were able to reduce or discontinue antidiabetic drugs.

CONCLUSION

The feasibility and initial efficacy of hSHIP were demonstrated.

PRACTICE IMPLICATION

This hybrid diabetes self-management model is a viable tool for traditionally underserved groups with diabetes or prediabetes.

Prevalence and molecular diversity of invasive Streptococcus dysgalactiae and Streptococcus pyogenes in a German tertiary care medical centre

Prevalence of invasive ß-haemolytic streptococci (BHS) at a tertiary care hospital and molecular diversity of S. pyogenes and S. dysgalactiae was studied. Between 2012 and 2016, all blood culture sets (n = 55,839), CSF (n = 8413) and soft tissue (n = 20,926) samples were analysed for BHS positivity using HYBASE software. Molecular profiles of 99 S. pyogenes and S. dysgalactiae were identified by sequencing of M protein genes (emm types) and multiplex PCR typing of 20 other virulence determinants. Streptococci contributed to 6.2% of blood, 10.7% of CSF and 14.5% of soft tissue isolates, being among the most common invasive isolates. The overall rates of invasive S. pyogenes, S. agalactiae, S. dysgalactiae and S. pneumoniae were 2.4, 4.4, 2.1, and 5.3%. Whereas S. pneumoniae was 1.5% more common in CSF samples, BHS isolates were 2-fold and 11-fold higher in bacteraemia and invasive soft tissue infections. Genetic BHS typing revealed wide molecular diversity of invasive and noninvasive group A and group G BHS, whereas one emm-type (stG62647.0) and no other virulence determinants except scpA were detected in invasive group C BHS. BHS were important invasive pathogens, outpacing S. pneumoniae in bacteraemia and invasive soft tissue infections. The incidence of S. dysgalactiae infections was comparable to that of S. pyogenes even with less diversity of molecular virulence. The results of this study emphasise the need for awareness of BHS invasiveness in humans and the need to develop BHS prevention strategies.

Healthcare costs of Type 2 diabetes in Germany

AIM

To describe for the first time the direct costs of Type 2 diabetes treatment by analysing nationwide routine data from statutory health insurance in Germany.

METHODS

This cost-of-illness-study was based on a 6.8% random sample of all German people with statutory health insurance (4.3 out of 70 million people). The healthcare expenses show direct per capita costs from the payer perspective. Healthcare expenses for physicians, dentists, pharmacies, hospitals, sick benefits and other healthcare costs were considered. Per capita costs, cost ratios for people with Type 2 diabetes and without diabetes as well as diabetes-attributable costs were calculated.

RESULTS

Per capita costs for people with Type 2 diabetes amounted to €4,957 in 2009 and €5,146 in 2010. People with Type 2 diabetes had 1.7-fold higher health expenses than people without diabetes. The largest differences in health expenses were found for prescribed medication from pharmacies (cost ratio diabetes/no diabetes: 2.2) and inpatient treatment (1.8). Ten percent of the total statutory health insurance expense, in total €16.1 billion, was attributable to the medical care of people with Type 2 diabetes.

CONCLUSIONS

This nationwide study indicates that one in 10 Euros of healthcare expenses is spent on people with Type 2 diabetes in Germany. In the future, national statutory health insurance data can be used to quantify time trends of costs in the healthcare system.

Successful Implementation of a Direct Observation Program in an Ambulatory Block Rotation

BACKGROUND

Direct observation of clinical skills is a cornerstone of competency-based education and training. Ensuring direct observation in a consistent fashion has been a significant challenge for residency programs.

OBJECTIVE

The purpose of this study was to evaluate the effects of a novel evaluation system, designed to achieve ongoing direct observation of residents, examine changes in resident observation practices, and understand faculty attitudes toward direct observation and the evaluation system.

METHODS

Internal medicine residents on an ambulatory block rotation participated in a new evaluation system, which replaced a single end-of-rotation summative evaluation with 9 formative evaluations based on direct observation. Faculty received training in direct observation and use of the forms, and residents were given responsibility to collect 9 observations per rotation. Faculty members contacted residents at the beginning and middle of the rotation to ensure completion of the observations. Residents and faculty also completed postrotation surveys to gauge the impact of the new system.

RESULTS

A total of 507 patient encounters were directly observed, and 52 of 57 (91%) residents completed all 9 observations. Residents reported considerably more direct observation than prior to the intervention, and most reported changes to their clinical skills based on faculty feedback. Faculty reported improvements in their attitudes, increased their use of direct observation, and preferred the new system to the old one.

CONCLUSIONS

A novel evaluation system replacing summative evaluations with multiple formative evaluations based on direct observation was successful in achieving high rates of observations, and improving faculty attitudes toward direct observation.

Heads Up: Communication Is Key in School Nurses' Preparedness for Facilitating "Return to Learn" Following Concussion

BACKGROUND

Recent literature advocates for a school academic team, including school nurses, to support concussed students' return to the classroom. This study aimed to assess the current understanding and practices of a sample of school nurses regarding the concept of "return to learn" in concussed students.

METHODS

Cross-sectional survey of New England school nurses.

RESULTS

The greatest barrier to the school nurses' functioning within the academic rehabilitation team for students with concussion was "inadequate communication with the provider that diagnosed the concussion" (73%). Of the 151 school nurses surveyed, 19% felt that they did not have the training necessary for this role. Other barriers included "inadequate concussion training" (38%) and "inadequate time necessary to care for a student with concussion" (30%).

CONCLUSIONS

By identifying specific gaps in knowledge and challenges at the school level, these results inform interdisciplinary medical teams about the importance of educating and facilitating effective "return to learn" academic plans.

Psychiatric sequelae following surgical treatment of breast cancer

Breast cancer has been the most carefully studied site of tumor from a psychological point of view. A range of interventions have been developed to assist the woman and her family in the emotional adjustment to breast cancer and its treatment. Many of these have been developed 'by women for women' and by their insistence that the medical community give more attention to this aspect of medical care. Rehabilitation now centers far more on breast reconstruction then previously. The psychologic understanding of problems posed by breast cancer has been used to develop rational and appropriate psychosocial interventions to reduce emotional distress. This model for development of support in breast cancer should be applied to psychologic management of patients with cancers of other sites, particularly those that carry high emotional distress and that place extensive demand on an individual's adaptive capacities.

Isolated linear skull fractures in children with blunt head trauma

BACKGROUND AND OBJECTIVE

Children and adolescents with minor blunt head trauma and isolated skull fractures are often admitted to the hospital. The objective of this study was to describe the injury circumstances and frequency of clinically important neurologic complications among children with minor blunt head trauma and isolated linear skull fractures.

METHODS

This study was a planned secondary analysis of a large prospective cohort study in children <18 years old with blunt head trauma. Data were collected in 25 emergency departments. We analyzed patients with Glasgow Coma Scale scores of 14 or 15 and isolated linear skull fractures. We ascertained acute neurologic outcomes through clinical information collected during admission or via telephone or mail at least 1 week after the emergency department visit.

RESULTS

In the parent study, we enrolled 43,904 children (11,035 [25%] <2 years old). Of those with imaging studies, 350 had isolated linear skull fractures. Falls were the most common injury mechanism, accounting for 70% (81% for ages <2 years old). Of 201 hospitalized children, 42 had computed tomography or MRI repeated; 5 had new findings but none required neurosurgical intervention. Of 149 patients discharged from the hospital, 20 had repeated imaging, and none had new findings.

CONCLUSIONS

Children with minor blunt head trauma and isolated linear skull fractures are at very low risk of evolving other traumatic findings noted in subsequent imaging studies or requiring neurosurgical intervention. Hospital admission for neurologically normal children with isolated linear skull fractures after minor blunt head trauma for monitoring is typically unnecessary.