Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Dissemination and implementation science resources, training, and scientific activities provided through CTSA programs nationally: Opportunities to advance D&I research and training capacity

Introduction

Clinical and Translational Science Award (CTSA) Program hubs are well-positioned to advance dissemination and implementation (D&I) research and training capacity nationally, though little is known about what D&I research support and services CTSAs provide. To address this gap, the CTSA Dissemination, Implementation, and Knowledge Transfer Working Group conducted an environmental scan of CTSAs (2017-2018).

Methods

Of 67 CTSA institutions, we contacted 43 that previously reported delivering D&I research services. D&I experts from these institutions were emailed a survey assessing D&I resources, services, training, and scientific projects. Responses were categorized and double-coded by study authors using a content analysis approach.

Results

Thirty-five of the 43 D&I experts (81.4%) responded. Challenges to CTSAs in developing and supporting D&I science activities were related to inadequate D&I science workforce (45.7%) and lack of understanding of D&I science (25.7%). Services provided included consultation/mentoring programs (68%), pilot funding/grants (50%), and workshops/seminars/conferences (46%). Training and workforce development in D&I were frequently identified as future priorities. Recommendations included increase training to meet demand (68.6%), accessible D&I tools/resources (34.3%), greater visibility/awareness of D&I methods (34.3%), consultation services (22.9%), and expand D&I science workforce (22.9%).

Conclusions

CTSAs have tremendous potential to support the advancement and impact of D&I science across the translational continuum. Despite the growing presence of D&I science in CTSAs, continued commitment and prioritization are needed from CTSA and institutional leadership to raise awareness of D&I science and its value, meet training demands, and develop necessary infrastructure for conducting D&I science.

Community-Academic Partnership to Improve Nutrition and Blood Pressure in Seniors: Outcomes & Impact of COVID-19

The Dietary Approaches to Stop Hypertension (“DASH diet”) has been proven in research settings to lower blood pressure, but its implementation is untested among seniors in congregate meals settings. We report the planning, implementation, impact of COVID-19, and results of an Administration of Community Living-funded study to test whether two evidence-based interventions - DASH-alignment of congregate meals, and home blood pressure self-monitoring, can lower systolic blood pressure and increase blood pressure control among community-dwelling seniors.. Congregate meal menus were aligned with the DASH eating plan, through collaboration of Bionutrition professionals on the research team, CBN food services leadership, and the NYC Department for the Aging. Seniors provided feedback on the DASH-modified meal options. The intervention began on October 15, 2019 (Site 1) and February 3, 2020 (Site 2). The study was interrupted by the COVID-19 pandemic in March 2020, when congregate meals ceased, and when approximately 75% of primary outcome data were collected. Modified implementation permitted completion of modified study outcomes. Preliminary analyses suggest that some participants were able to lower their blood pressure in this program. The DASH diet implemented in the congregate meal setting, along with programs to support BP self-efficacy through modification of existing programs, may be a valuable and scalable model to reduce cardiovascular risk among community-living seniors.

Characteristics and outcomes of AED use in pediatric cardiac arrest in public settings: The influence of neighborhood characteristics

BACKGROUND

Automated external defibrillators (AEDs) are critical in the chain of survival following out-of-hospital cardiac arrest (OHCA), yet few studies have reported on AED use and outcomes among pediatric OHCA. This study describes the association between bystander AED use, neighborhood characteristics and survival outcomes following public pediatric OHCA.

METHODS

Non-traumatic OHCAs among children less than18 years of age in a public setting between from January 1, 2013 through December 31, 2017 were identified in the CARES database. A neighborhood characteristic index was created from the addition of dichotomous values of 4 American Community Survey neighborhood characteristics at the Census tract level: median household income, percent high school graduates, percent unemployment, and percent African American. Multivariable logistic regression models assessed the association of OHCA characteristics, the neighborhood characteristic index and outcomes.

RESULTS

Of 971 pediatric OHCA, AEDs were used by bystanders in 10.3% of OHCAs. AEDs were used on 2.3% of children ≤1 year (infants), 8.3% of 2-5 year-olds, 12.4% of 6-11 year-olds, and 18.2% of 12-18 year-olds (p < 0.001). AED use was more common in neighborhoods with a median household income of >$50,000 per year (12.3%; p = 0.016), <10% unemployment (12.1%; p = 0.002), and >80% high school education (11.8%; p = 0.002). Greater survival to hospital discharge and neurologically favorable survival were among arrests with bystander AED use, varying by neighborhood characteristics.

CONCLUSIONS

Bystander AED use is uncommon in pediatric OHCA, particularly in high-risk neighborhoods, but improves survival. Further study is needed to understand disparities in AED use and outcomes.

Process evaluation of a cluster-randomised controlled trial of multi-component weight management programme in adults with intellectual disabilities and obesity

BACKGROUND

Providing effective weight management to adults with intellectual disabilities is necessary to challenge the high rates of obesity. The aim of this process evaluation was to explore the feasibility of conducting a full-scale clinical trial of the TAKE 5 multi-component weight management programme.

METHODS

The study was a 12-month pilot cluster-randomised controlled trial. Adults with intellectual disabilities and obesity were randomised to either TAKE 5, which included an energy deficit diet (EDD) or Waist Winners Too, based on health education principles. A mixed-methods process evaluation was conducted focussing on the reach, recruitment, fidelity, implementation, dose (delivered/received) and context.

RESULTS

The study successfully recruited adults with intellectual disabilities. Both weight management programmes were delivered with high fidelity and implemented as intended. Only one weight management programme, TAKE 5, demonstrated potential efficacy in reducing body weight and body composition. The effectiveness was largely attributed to the EDD and social support from carers.

CONCLUSIONS

The extensive process evaluation illustrated that a full-scale trial of a multi-component programme including an EDD is feasible and an acceptable approach to weight management for adults with intellectual disabilities and obesity.

Predictors of Changes in Medication Adherence in Blacks with Hypertension: Moving Beyond Cross-Sectional Data

BACKGROUND

Many studies have examined the multiple correlates of non-adherence in Blacks. However, they are largely cross-sectional; thus, these studies are unable to examine their predictive value on long-term medication adherence.

PURPOSE

The purpose of this study is to examine the predictive role of key psychosocial and interpersonal factors on changes in medication adherence over a 1-year period.

METHODS

Data were collected from 815 Black patients with hypertension followed in community health centers. Hypothesized predictor variables included self-efficacy, depressive symptoms, social support, and patient-provider communication measured at baseline, 6, and 12 months. The dependent variable, medication adherence was assessed at baseline, 6, and 12 months. Latent Growth Modeling was used to evaluate the pathways between the latent predictor variables and medication adherence.

RESULTS

Participants were mostly female, low-income, with high school education or less, and mean age of 57 years. At baseline, high self-efficacy was associated with low depressive symptoms (β = -0.22, p = 0.05), collaborative patient-provider communication (β = 0.17, p = 0.006), and better medication adherence (β = 1.04, p < 0.001). More social support and collaborative patient-provider communication were associated with low depressive symptoms (β = -0.08, p = 0.02; β = -0.18, p = 0.01). More social support was positively associated with collaborative patient-provider communication (β = 0.32, p < 0.001). In the longitudinal model, increasing self-efficacy over time predicted improvements in medication adherence 1 year later (β = 1.76, p < 0.001; CFI = 0.95; RMSEA = 0.04; SRMR = 0.04; Chi-Squared Index of Model Fit = 1128.54).

CONCLUSIONS

Self-efficacy is a key predictor of medication adherence over time in Black patients with hypertension. Initial levels of self-efficacy are influenced by the presence of depressive symptoms as well as the perceived quality of patient-provider communication.

The effect of storage conditions on the composition and functional properties of blended bulk tank milk

The objective of this study was to investigate the effects of storage temperature and duration on the composition and functional properties of bulk tank milk when fresh milk was added to the bulk tank twice daily. The bulk tank milk temperature was set at each of 3 temperatures (2, 4, and 6°C) in each of 3 tanks on 2 occasions during two 6-wk periods. Period 1 was undertaken in August and September when all cows were in mid lactation, and period 2 was undertaken in October and November when all cows were in late lactation. Bulk tank milk stored at the 3 temperatures was sampled at 24-h intervals during storage periods of 0 to 96 h. Compositional parameters were measured for all bulk tank milk samples, including gross composition and quantification of nitrogen compounds, casein fractions, free amino acids, and Ca and P contents. The somatic cell count, heat stability, titratable acidity, and rennetability of bulk tank milk samples were also assessed. Almost all parameters differed between mid and late lactation; however, the interaction between lactation, storage temperature, and storage duration was significant for only 3 parameters: protein content and concentrations of free cysteic acid and free glutamic acid. The interaction between storage temperature and storage time was not significant for any parameter measured, and temperature had no effect on any parameter except lysine: lysine content was higher at 6°C than at 2°C. During 96 h of storage, the concentrations of some free amino acids (glutamic acid, lysine, and arginine) increased, which may indicate proteolytic activity during storage. Between 0 and 96 h, minimal deterioration was observed in functional properties (rennet coagulation time, curd firmness, and heat stability), which was most likely due to the dissociation of β-casein from the casein micelle, which can be reversed upon pasteurization. Thus, this study suggests that blended milk can be stored for up to 96 h at temperatures between 2°C and 6°C with little effect on its composition or functional properties.

Proceedings of the 8th Annual Conference on the Science of Dissemination and Implementation : Washington, DC, USA. 14-15 December 2015

A1 Introduction to the 8^th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health

David Chambers, Lisa Simpson

D1 Discussion forum: Population health D&I research

Felicia Hill-Briggs

D2 Discussion forum: Global health D&I research

Gila Neta, Cynthia Vinson

D3 Discussion forum: Precision medicine and D&I research

David Chambers

S1 Predictors of community therapists’ use of therapy techniques in a large public mental health system

Rinad Beidas, Steven Marcus, Gregory Aarons, Kimberly Hoagwood, Sonja Schoenwald, Arthur Evans, Matthew Hurford, Ronnie Rubin, Trevor Hadley, Frances Barg, Lucia Walsh, Danielle Adams, David Mandell

S2 Implementing brief cognitive behavioral therapy (CBT) in primary care: Clinicians' experiences from the field

Lindsey Martin, Joseph Mignogna, Juliette Mott, Natalie Hundt, Michael Kauth, Mark Kunik, Aanand Naik, Jeffrey Cully

S3 Clinician competence: Natural variation, factors affecting, and effect on patient outcomes

Alan McGuire, Dominique White, Tom Bartholomew, John McGrew, Lauren Luther, Angie Rollins, Michelle Salyers

S4 Exploring the multifaceted nature of sustainability in community-based prevention: A mixed-method approach

Brittany Cooper, Angie Funaiole

S5 Theory informed behavioral health integration in primary care: Mixed methods evaluation of the implementation of routine depression and alcohol screening and assessment

Julie Richards, Amy Lee, Gwen Lapham, Ryan Caldeiro, Paula Lozano, Tory Gildred, Carol Achtmeyer, Evette Ludman, Megan Addis, Larry Marx, Katharine Bradley

S6 Enhancing the evidence for specialty mental health probation through a hybrid efficacy and implementation study

Tonya VanDeinse, Amy Blank Wilson, Burgin Stacey, Byron Powell, Alicia Bunger, Gary Cuddeback

S7 Personalizing evidence-based child mental health care within a fiscally mandated policy reform

Miya Barnett, Nicole Stadnick, Lauren Brookman-Frazee, Anna Lau

S8 Leveraging an existing resource for technical assistance: Community-based supervisors in public mental health

Shannon Dorsey, Michael Pullmann

S9 SBIRT implementation for adolescents in urban federally qualified health centers: Implementation outcomes

Shannon Mitchell, Robert Schwartz, Arethusa Kirk, Kristi Dusek, Marla Oros, Colleen Hosler, Jan Gryczynski, Carolina Barbosa, Laura Dunlap, David Lounsbury, Kevin O'Grady, Barry Brown

S10 PANEL: Tailoring Implementation Strategies to Context - Expert recommendations for tailoring strategies to context

Laura Damschroder, Thomas Waltz, Byron Powell

S11 PANEL: Tailoring Implementation Strategies to Context - Extreme facilitation: Helping challenged healthcare settings implement complex programs

Mona Ritchie

S12 PANEL: Tailoring Implementation Strategies to Context - Using menu-based choice tasks to obtain expert recommendations for implementing three high-priority practices in the VA

Thomas Waltz

S13 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Siri, rate my therapist: Using technology to automate fidelity ratings of motivational interviewing

David Atkins, Zac E. Imel, Bo Xiao, Doğan Can, Panayiotis Georgiou, Shrikanth Narayanan

S14 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Identifying indicators of implementation quality for computer-based ratings

Cady Berkel, Carlos Gallo, Irwin Sandler, C. Hendricks Brown, Sharlene Wolchik, Anne Marie Mauricio

S15 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Improving implementation of behavioral interventions by monitoring emotion in spoken speech

Carlos Gallo, C. Hendricks Brown, Sanjay Mehrotra

S16 Scorecards and dashboards to assure data quality of health management information system (HMIS) using R

Dharmendra Chandurkar, Siddhartha Bora, Arup Das, Anand Tripathi, Niranjan Saggurti, Anita Raj

S17 A big data approach for discovering and implementing patient safety insights

Eric Hughes, Brian Jacobs, Eric Kirkendall

S18 Improving the efficacy of a depression registry for use in a collaborative care model

Danielle Loeb, Katy Trinkley, Michael Yang, Andrew Sprowell, Donald Nease

S19 Measurement feedback systems as a strategy to support implementation of measurement-based care in behavioral health

Aaron Lyon, Cara Lewis, Meredith Boyd, Abigail Melvin, Semret Nicodimos, Freda Liu, Nathanial Jungbluth

S20 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Common loop assay: Methods of supporting learning collaboratives

Allen Flynn

S21 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Innovating audit and feedback using message tailoring models for learning health systems

Zach Landis-Lewis

S22 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Implementation science and learning health systems: Connecting the dots

Anne Sales

S23 Facilitation activities of Critical Access Hospitals during TeamSTEPPS implementation

Jure Baloh, Marcia Ward, Xi Zhu

S24 Organizational and social context of federally qualified health centers and variation in maternal depression outcomes

Ian Bennett, Jurgen Unutzer, Johnny Mao, Enola Proctor, Mindy Vredevoogd, Ya-Fen Chan, Nathaniel Williams, Phillip Green

S25 Decision support to enhance treatment of hospitalized smokers: A randomized trial

Steven Bernstein, June-Marie Rosner, Michelle DeWitt, Jeanette Tetrault, James Dziura, Allen Hsiao, Scott Sussman, Patrick O’Connor, Benjamin Toll

S26 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - A patient-centered approach to successful community transition after catastrophic injury

Michael Jones, Julie Gassaway

S27 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - Conducting PCOR to integrate mental health and cancer screening services in primary care

Jonathan Tobin

S28 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - A comparative effectiveness trial of optimal patient-centered care for US trauma care systems

Douglas Zatzick

S29 Preferences for in-person communication among patients in a multi-center randomized study of in-person versus telephone communication of genetic test results for cancer susceptibility

Angela R Bradbury, Linda Patrick-Miller, Brian Egleston, Olufunmilayo I Olopade, Michael J Hall, Mary B Daly, Linda Fleisher, Generosa Grana, Pamela Ganschow, Dominique Fetzer, Amanda Brandt, Dana Farengo-Clark, Andrea Forman, Rikki S Gaber, Cassandra Gulden, Janice Horte, Jessica Long, Rachelle Lorenz Chambers, Terra Lucas, Shreshtha Madaan, Kristin Mattie, Danielle McKenna, Susan Montgomery, Sarah Nielsen, Jacquelyn Powers, Kim Rainey, Christina Rybak, Michelle Savage, Christina Seelaus, Jessica Stoll, Jill Stopfer, Shirley Yao and Susan Domchek

S30 Working towards de-implementation: A mixed methods study in breast cancer surveillance care

Erin Hahn, Corrine Munoz-Plaza, Jianjin Wang, Jazmine Garcia Delgadillo, Brian Mittman Michael Gould

S31Integrating evidence-based practices for increasing cancer screenings in safety-net primary care systems: A multiple case study using the consolidated framework for implementation research

Shuting (Lily) Liang, Michelle C. Kegler, Megan Cotter, Emily Phillips, April Hermstad, Rentonia Morton, Derrick Beasley, Jeremy Martinez, Kara Riehman

S32 Observations from implementing an mHealth intervention in an FQHC

David Gustafson, Lisa Marsch, Louise Mares, Andrew Quanbeck, Fiona McTavish, Helene McDowell, Randall Brown, Chantelle Thomas, Joseph Glass, Joseph Isham, Dhavan Shah

S33 A multicomponent intervention to improve primary care provider adherence to chronic opioid therapy guidelines and reduce opioid misuse: A cluster randomized controlled trial protocol

Jane Liebschutz, Karen Lasser

S34 Implementing collaborative care for substance use disorders in primary care: Preliminary findings from the summit study

Katherine Watkins, Allison Ober, Sarah Hunter, Karen Lamp, Brett Ewing

S35 Sustaining a task-shifting strategy for blood pressure control in Ghana: A stakeholder analysis

Juliet Iwelunmor, Joyce Gyamfi, Sarah Blackstone, Nana Kofi Quakyi, Jacob Plange-Rhule, Gbenga Ogedegbe

S36 Contextual adaptation of the consolidated framework for implementation research (CFIR) in a tobacco cessation study in Vietnam

Pritika Kumar, Nancy Van Devanter, Nam Nguyen, Linh Nguyen, Trang Nguyen, Nguyet Phuong, Donna Shelley

S37 Evidence check: A knowledge brokering approach to systematic reviews for policy

Sian Rudge

S38 Using Evidence Synthesis to Strengthen Complex Health Systems in Low- and Middle-Income Countries

Etienne Langlois

S39 Does it matter: timeliness or accuracy of results? The choice of rapid reviews or systematic reviews to inform decision-making

Andrea Tricco

S40 Evaluation of the veterans choice program using lean six sigma at a VA medical center to identify benefits and overcome obstacles

Sherry Ball, Anne Lambert-Kerzner, Christine Sulc, Carol Simmons, Jeneen Shell-Boyd, Taryn Oestreich, Ashley O'Connor, Emily Neely, Marina McCreight, Amy Labebue, Doreen DiFiore, Diana Brostow, P. Michael Ho, David Aron

S41 The influence of local context on multi-stakeholder alliance quality improvement activities: A multiple case study

Jillian Harvey, Megan McHugh, Dennis Scanlon

S42 Increasing physical activity in early care and education: Sustainability via active garden education (SAGE)

Rebecca Lee, Erica Soltero, Nathan Parker, Lorna McNeill, Tracey Ledoux

S43 Marking a decade of policy implementation: The successes and continuing challenges of a provincial school food and nutrition policy in Canada

Jessie-Lee McIsaac, Kate MacLeod, Nicole Ata, Sherry Jarvis, Sara Kirk

S44 Use of research evidence among state legislators who prioritize mental health and substance abuse issues

Jonathan Purtle, Elizabeth Dodson, Ross Brownson

S45 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 1 designs

Brian Mittman, Geoffrey Curran

S46 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 2 designs

Geoffrey Curran

S47 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 3 designs

Jeffrey Pyne

S48 Linking team level implementation leadership and implementation climate to individual level attitudes, behaviors, and implementation outcomes

Gregory Aarons, Mark Ehrhart, Elisa Torres

S49 Pinpointing the specific elements of local context that matter most to implementation outcomes: Findings from qualitative comparative analysis in the RE-inspire study of VA acute stroke care

Edward Miech

S50 The GO score: A new context-sensitive instrument to measure group organization level for providing and improving care

Edward Miech

S51 A research network approach for boosting implementation and improvement

Kathleen Stevens, I.S.R.N. Steering Council

S52 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - The value of qualitative methods in implementation research

Alison Hamilton

S53 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - Learning evaluation: The role of qualitative methods in dissemination and implementation research

Deborah Cohen

S54 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - Qualitative methods in D&I research

Deborah Padgett

S55 PANEL: Maps & models: The promise of network science for clinical D&I - Hospital network of sharing patients with acute and chronic diseases in California

Alexandra Morshed

S56 PANEL: Maps & models: The promise of network science for clinical D&I - The use of social network analysis to identify dissemination targets and enhance D&I research study recruitment for pre-exposure prophylaxis for HIV (PrEP) among men who have sex with men

Rupa Patel

S57 PANEL: Maps & models: The promise of network science for clinical D&I - Network and organizational factors related to the adoption of patient navigation services among rural breast cancer care providers

Beth Prusaczyk

S58 A theory of de-implementation based on the theory of healthcare professionals’ behavior and intention (THPBI) and the becker model of unlearning

David C. Aron, Divya Gupta, Sherry Ball

S59 Observation of registered dietitian nutritionist-patient encounters by dietetic interns highlights low awareness and implementation of evidence-based nutrition practice guidelines

Rosa Hand, Jenica Abram, Taylor Wolfram

S60 Program sustainability action planning: Building capacity for program sustainability using the program sustainability assessment tool

Molly Hastings, Sarah Moreland-Russell

S61 A review of D&I study designs in published study protocols

Rachel Tabak, Alex Ramsey, Ana Baumann, Emily Kryzer, Katherine Montgomery, Ericka Lewis, Margaret Padek, Byron Powell, Ross Brownson

S62 PANEL: Geographic variation in the implementation of public health services: Economic, organizational, and network determinants - Model simulation techniques to estimate the cost of implementing foundational public health services

Cezar Brian Mamaril, Glen Mays, Keith Branham, Lava Timsina

S63 PANEL: Geographic variation in the implementation of public health services: Economic, organizational, and network determinants - Inter-organizational network effects on the implementation of public health services

Glen Mays, Rachel Hogg

S64 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Implementation fidelity, coalition functioning, and community prevention system transformation using communities that care

Abigail Fagan, Valerie Shapiro, Eric Brown

S65 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Expanding capacity for implementation of communities that care at scale using a web-based, video-assisted training system

Kevin Haggerty, David Hawkins

S66 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Effects of communities that care on reducing youth behavioral health problems

Sabrina Oesterle, David Hawkins, Richard Catalano

S68 When interventions end: the dynamics of intervention de-adoption and replacement

Virginia McKay, M. Margaret Dolcini, Lee Hoffer

S69 Results from next-d: can a disease specific health plan reduce incident diabetes development among a national sample of working-age adults with pre-diabetes?

Tannaz Moin, Jinnan Li, O. Kenrik Duru, Susan Ettner, Norman Turk, Charles Chan, Abigail Keckhafer, Robert Luchs, Sam Ho, Carol Mangione

S70 Implementing smoking cessation interventions in primary care settings (STOP): using the interactive systems framework

Peter Selby, Laurie Zawertailo, Nadia Minian, Dolly Balliunas, Rosa Dragonetti, Sarwar Hussain, Julia Lecce

S71 Testing the Getting To Outcomes implementation support intervention in prevention-oriented, community-based settings

Matthew Chinman, Joie Acosta, Patricia Ebener, Patrick S Malone, Mary Slaughter

S72 Examining the reach of a multi-component farmers’ market implementation approach among low-income consumers in an urban context

Darcy Freedman, Susan Flocke, Eunlye Lee, Kristen Matlack, Erika Trapl, Punam Ohri-Vachaspati, Morgan Taggart, Elaine Borawski

S73 Increasing implementation of evidence-based health promotion practices at large workplaces: The CEOs Challenge

Amanda Parrish, Jeffrey Harris, Marlana Kohn, Kristen Hammerback, Becca McMillan, Peggy Hannon

S74 A qualitative assessment of barriers to nutrition promotion and obesity prevention in childcare

Taren Swindle, Geoffrey Curran, Leanne Whiteside-Mansell, Wendy Ward

S75 Documenting institutionalization of a health communication intervention in African American churches

Cheryl Holt, Sheri Lou Santos, Erin Tagai, Mary Ann Scheirer, Roxanne Carter, Janice Bowie, Muhiuddin Haider, Jimmie Slade, Min Qi Wang

S76 Reduction in hospital utilization by underserved patients through use of a community-medical home

Andrew Masica, Gerald Ogola, Candice Berryman, Kathleen Richter

S77 Sustainability of evidence-based lay health advisor programs in African American communities: A mixed methods investigation of the National Witness Project

Rachel Shelton, Lina Jandorf, Deborah Erwin

S78 Predicting the long-term uninsured population and analyzing their gaps in physical access to healthcare in South Carolina

Khoa Truong

S79 Using an evidence-based parenting intervention in churches to prevent behavioral problems among Filipino youth: A randomized pilot study

Joyce R. Javier, Dean Coffey, Sheree M. Schrager, Lawrence Palinkas, Jeanne Miranda

S80 Sustainability of elementary school-based health centers in three health-disparate southern communities

Veda Johnson, Valerie Hutcherson, Ruth Ellis

S81 Childhood obesity prevention partnership in Louisville: creative opportunities to engage families in a multifaceted approach to obesity prevention

Anna Kharmats, Sandra Marshall-King, Monica LaPradd, Fannie Fonseca-Becker

S82 Improvements in cervical cancer prevention found after implementation of evidence-based Latina prevention care management program

Deanna Kepka, Julia Bodson, Echo Warner, Brynn Fowler

S83 The OneFlorida data trust: Achieving health equity through research & training capacity building

Elizabeth Shenkman, William Hogan, Folakami Odedina, Jessica De Leon, Monica Hooper, Olveen Carrasquillo, Renee Reams, Myra Hurt, Steven Smith, Jose Szapocznik, David Nelson, Prabir Mandal

S84 Disseminating and sustaining medical-legal partnerships: Shared value and social return on investment

James Teufel

The case in favour of probiotics before, during and after pregnancy: insights from the first 1,500 days

Successful human reproduction requires microbial homeostasis in the female reproductive tract, and colonisation of the newborn with beneficial microbes. In order to prevent several complications associated with dysbiosis, the administration of probiotics is more often being considered. The objective of the enclosed review was to examine the rationale for probiotic utility before and during pregnancy and in the early phase of infant life. The conclusions emerged from a panel of researchers who met during the International Scientific Association for Probiotics and Prebiotics (ISAPP) workshop held in Washington, DC, USA in 2015. The group concluded based upon the current literature, that a case can be made for the use of a specific sets of probiotic organisms during the first 1,500 days of life, with the goal of a healthy pregnancy to term, and a healthy start to life with lowered risk of infections and inflammatory events. The key to successfully translating these recommendations to practice is that products be made available and affordable to women in developed and developing countries.

Exploring Group Composition among Young, Urban Women of Color in Prenatal Care: Implications for Satisfaction, Engagement, and Group Attendance

PURPOSE

Group models of prenatal care continue to grow in popularity. However, little is known about how group composition (similarity or diversity between members of groups) relates to care-related outcomes. The current investigation aimed to explore associations between prenatal care group composition with patient satisfaction, engagement, and group attendance among young, urban women of color.

METHODS

Data were drawn from two studies conducted in New Haven and Atlanta (2001-2004; n = 557) and New York City (2008-2011; n = 375) designed to evaluate group prenatal care among young, urban women of color. Women aged 14 to 25 were assigned to group prenatal care and completed surveys during their second and third trimesters of pregnancy. Group attendance was recorded. Data were merged and analyzed guided by the Group Actor-Partner Interdependence Model using multilevel regression. Analyses explored composition in terms of age, race, ethnicity, and language.

MAIN FINDINGS

Women in groups with others more diverse in age reported greater patient engagement and, in turn, attended more group sessions, b(se) = -0.01(0.01); p = .04.

CONCLUSION

The composition of prenatal care groups seems to be associated with young women's engagement in care, ultimately relating to the number of group prenatal care sessions they attend. Creating groups diverse in age may be particularly beneficial for young, urban women of color, who have unique pregnancy needs and experiences. Future research is needed to test the generalizability of these exploratory findings.

Activation of persons living with HIV for treatment, the great study

Background

Patient empowerment represents a potent tool for addressing racial, ethnic and socioeconomic disparities in health care, particularly for chronic conditions such as HIV infection that require active patient engagement. This multimodal intervention, developed in concert with HIV patients and clinicians, aims to provide HIV patients with the knowledge, skills, attitudes and tools to become more activated patients.

Methods/Design

Randomized controlled trial of a multimodal intervention designed to activate persons living with HIV. The intervention includes four components: 1) use of a web-enabled hand-held device (Apple iPod Touch) loaded with a Personal Health Record (ePHR) customized for HIV patients; 2) six 90-minute group-based training sessions in use of the device, internet and the ePHR; 3) a pre-visit coaching session; and 4) clinician education regarding how they can support activated patients. Outcome measures include pre- post changes in patient activation measure score (primary outcome), eHealth literacy, patient involvement in decision-making and care, medication adherence, preventive care, and HIV Viral Load.

Discussion

We hypothesize that participants receiving the intervention will show greater improvement in empowerment and the intervention will reduce disparities in study outcomes. Disparities in these measures will be smaller than those in the usual care group. Findings have implications for activating persons living with HIV and for other marginalized groups living with chronic illness.

Trial registration

ClinicalTrials.gov Identifier: NCT02165735, 6/13/2014.

Generation and validation of a zebrafish model of EAST (epilepsy, ataxia, sensorineural deafness and tubulopathy) syndrome

Recessive mutations in KCNJ10, which encodes an inwardly rectifying potassium channel, were recently identified as the cause of EAST syndrome, a severe and disabling multi-organ disorder consisting of epilepsy, ataxia, sensorineural deafness and tubulopathy that becomes clinically apparent with seizures in infancy. A Kcnj10 knockout mouse shows postnatal mortality and is therefore not suitable for drug discovery. Because zebrafish are ideal for in vivo screening for potential therapeutics, we tested whether kcnj10 knockdown in zebrafish would fill this need. We cloned zebrafish kcnj10 and demonstrated that its function is equivalent to that of human KCNJ10. We next injected splice- and translation-blocking kcnj10 antisense morpholino oligonucleotides and reproduced the cardinal symptoms of EAST syndrome – ataxia, epilepsy and renal tubular defects. Several of these phenotypes could be assayed in an automated manner. We could rescue the morphant phenotype with complementary RNA (cRNA) encoding human wild-type KCNJ10, but not with cRNA encoding a KCNJ10 mutation identified in individuals with EAST syndrome. Our results suggest that zebrafish will be a valuable tool to screen for compounds that are potentially therapeutic for EAST syndrome or its individual symptoms. Knockdown of kcnj10 represents the first zebrafish model of a salt-losing tubulopathy, which has relevance for blood pressure control.

The potential for a suite of isotope and chemical markers to differentiate sources of nitrate contamination: a review

Nitrate is naturally found within the environment as part of the nitrogen cycle. However, anthropogenic inputs have greatly increased nitrate loads within ground and surface waters. This has had a severe impact on aquatic ecosystems and has given rise to health considerations in humans and livestock. Therefore, the identification of nitrate sources is important in preserving water quality and achieving sustainability of our water resources. Nitrate sources can be determined based on the nitrate nitrogen (N) and oxygen (O) isotopic compositions (δ(15)N, δ(18)O). However, sewage and manure have overlapping δ(15)N and δ(18)O values making their differentiation on this basis problematic. The specific differentiation between sources of faecal contamination is of particular importance, because the risk to humans is usually considered higher from human faecal contamination (sewage) than from animal faecal contamination. This review summarises the current state of knowledge in using isotope tracers to differentiate various nitrate sources and identifies potential chemical tracers for differentiating sewage and manure. In particular, an in depth review of the current state of knowledge regarding the necessary considerations in using chemical markers, such as pharmaceuticals and food additives, to differentiate sewage and manure sources of nitrate contamination will be given, through an understanding of their use, occurrence and fate, in order to identify the most suitable potential chemical markers.

Short-term frovatriptan for the prevention of difficult-to-treat menstrual migraine attacks

The efficacy of a 6-day regimen of frovatriptan for menstrual migraine (MM; attacks starting on day -2 to +3 of menses) prevention in women with difficult-to-treat MM was assessed. Women with a documented inadequate response to triptans for acute MM treatment were included in this placebo-controlled, parallel-group trial. Women were randomized to double-blind treatment for three perimenstrual periods (PMPs) with either frovatriptan 2.5 mg (q.d. or b.i.d.) or placebo initiated 2 days before anticipated MM. The efficacy analysis included 410 women with 85% completing three double-blind PMPs. The mean number of headache-free PMPs was 0.92 with frovatriptan b.i.d., 0.69 with frovatriptan q.d. and 0.42 with placebo [P < 0.001 (b.i.d.) and P < 0.02 (q.d.) vs. placebo]. When migraine occurred, severity was reduced with frovatriptan q.d. (P < 0.001) and b.i.d. (P < 0.001) vs. placebo. Both frovatriptan regimens were well tolerated. In women with difficult-to-treat MM, a 6-day regimen of frovatriptan significantly reduced MM incidence and severity.

Epilepsy, ataxia, sensorineural deafness, tubulopathy, and KCNJ10 mutations

BACKGROUND

Five children from two consanguineous families presented with epilepsy beginning in infancy and severe ataxia, moderate sensorineural deafness, and a renal salt-losing tubulopathy with normotensive hypokalemic metabolic alkalosis. We investigated the genetic basis of this autosomal recessive disease, which we call the EAST syndrome (the presence of epilepsy, ataxia, sensorineural deafness, and tubulopathy).

METHODS

Whole-genome linkage analysis was performed in the four affected children in one of the families. Newly identified mutations in a potassium-channel gene were evaluated with the use of a heterologous expression system. Protein expression and function were further investigated in genetically modified mice.

RESULTS

Linkage analysis identified a single significant locus on chromosome 1q23.2 with a lod score of 4.98. This region contained the KCNJ10 gene, which encodes a potassium channel expressed in the brain, inner ear, and kidney. Sequencing of this candidate gene revealed homozygous missense mutations in affected persons in both families. These mutations, when expressed heterologously in xenopus oocytes, caused significant and specific decreases in potassium currents. Mice with Kcnj10 deletions became dehydrated, with definitive evidence of renal salt wasting.

CONCLUSIONS

Mutations in KCNJ10 cause a specific disorder, consisting of epilepsy, ataxia, sensorineural deafness, and tubulopathy. Our findings indicate that KCNJ10 plays a major role in renal salt handling and, hence, possibly also in blood-pressure maintenance and its regulation.

Impingement Cooking of Meat Products: Effect of Variability on Final Temperature

Heat transfer coefficient (HTC) for chicken fillets and beef burgers were determined at a number of product-to-tube distances in an impingement air unit. The coefficient varied from < 100 W/m2 K to over 200 W/m2 K depending on the input parameter settings. The level of variation in the coefficient between adjacent product items in the oven has been quantified as ±20 W/m 2 K. Models of sheat transfer for both food products have been developed. Parameter of the models indicated that depending on the product, either dimensional variation in the product or dispersion in the HTC between products can make the dominant contribution to dispersion in final product temperature.

Polymorphic microRNA-target interactions: a novel source of phenotypic variation

Studying the muscular hypertrophy of Texel sheep by forward genetics, we have identified an A-to-G transition in the 3'UTR of the GDF8 gene that reveals an illegitimate target site for microRNAs miR-1 and miR-206 that are highly expressed in skeletal muscle. This causes the down-regulation of this muscle-specific chalone and hence contributes to the muscular hypertrophy of Texel sheep. We demonstrate that polymorphisms which alter the content of putative miRNA target sites are common in human and mice, and provide evidence that both conserved and nonconserved target sites are selectively constrained. We speculate that these polymorphisms might be important mediators of phenotypic variation including disease. To facilitate studies along those lines, we have constructed a database (www.patrocles.org) listing putative polymorphic microRNA-target interactions.

Roll-out of a nurse-led welfare benefits screening service throughout the largest Local Health Care Co-operative in Glasgow: an evaluation study

OBJECTIVE

To evaluate the roll-out of a nurse-led Attendance Allowance (AA) screening programme in 24 general practices located within the largest Local Health Care Co-operative in Glasgow.

STUDY DESIGN

Evaluation study

METHODS

Six hundred and thirty participants aged over 64 years who, in the nurses' clinical judgement, appeared to have care needs were recruited opportunistically by community nurses over a 15-month period. A money advice worker contacted all potential underclaimers offering a home visit to assess for unclaimed benefits. The main outcome measured was the total amount of unclaimed AA, linked benefits and grants.

RESULTS

Three hundred and sixty-three participants and 13 relatives were awarded a total of 1,136,424.10 pounds. Of this, 1,016,908.70 pounds was on a recurrent annual basis and 119,515.44 pounds was awarded as lump sums.

CONCLUSIONS

This method of benefits assessment (community-nurse-led pre-AA screening followed by a home visit from a money advice worker) would appear to be an efficient and effective method of income maximization that could be rolled out nationally within primary care settings located in deprived areas.

The challenges and ethical dilemmas of a military medical officer serving with a peacekeeping operation in regard to the medical care of the local population

Medical Officers serving with their national contingents in peacekeeping operations are faced with difficult ethical decisions in regard to their obligations to the local civilian population. Such populations may be under-resourced in regard to medical care, and vulnerable to abuse and exploitation. Though the medical officer may support the local medical services, he/she should never undermine these resources. Adopting a human rights approach and observing the requirements of ethical medicine, aids the doctor in prioritising his/her duties. At times there may be conflict with one's own military superiors. It is wise to discuss potential difficulties prior to setting out on the mission. Human rights abuses cannot be ignored. The medical officer has a duty to do his/her best to report their observations so as to prevent abuse or to bring it to an end.

The impact of improved self-efficacy on HIV viral load and distress in culturally diverse women living with AIDS: the SMART/EST Women's Project

The purpose of the present study was to determine whether changes in self-efficacy over time would be related to changes in disease progression markers (CD4, viral load) in a sample of women with AIDS. A self-efficacy measure was developed and two sub-scales emerged via factor analysis of 391 HIV-positive women: AIDS Self-efficacy and Cognitive Behavioral Skills Self-efficacy. Subsequently, the sub-scales and an additional adherence self-efficacy item were given to 56 HIV-positive women who were measured at two time points three months apart. Half of these women were randomly assigned to a CB intervention and half to a low intensity comparison condition. Increases in AIDS Self-efficacy over the three-month period were significantly related to increases in CD4 and decreases in viral load. Similarly, increases in Cognitive Behavioral Skills Self-efficacy were significantly related to decreases in distress over time. Findings were maintained within the intervention group alone. Interestingly, increases in cognitive behavioral skills self-efficacy and increases in the self-efficacy adherence item were also significantly related to decreases in viral load. Implications of the findings and suggestions for future research are discussed.

Sustained efficacy of nevirapine in combination with two nucleoside analogues in the treatment of HIV-infected patients: a 48-week retrospective multicenter study

BACKGROUND

Nevirapine, a nonnucleoside analogue, has demonstrated suppression of human immunodeficiency virus (HIV) replication alone and in combination therapy. However, the durable suppression of HIV with nevirapine when used along with other nucleosides in HIV-infected patients who are treated in clinical practice needs further evaluation.

PURPOSE

To evaluate the sustained efficacy of nevirapine in combination with two nucleoside analogues in the treatment of HIV-infected patients in routine clinical practice.

DESIGN

A multicenter study from January 1997 to December 2000, with follow-up through 48 weeks, was conducted at four different genitourinary medicine clinics in the United Kingdom. Forty-four HIV-infected patients received nevirapine and two nucleoside analogues. Information from case notes regarding age, sex, side effects, viral load, and CD4 lymphocyte counts at baseline, 24 weeks, and 48 weeks was collected and analyzed. Virologic suppression, defined as HIV RNA concentration of less than 400 copies/mL at Weeks 24 and 48, was considered as the main outcome measure.

RESULTS

Out of 44 patients, 41 were men with a mean age of 39.3 years (95% CI 36.7-41.8). The baseline viral load was 2.11 x 10(2) to 9.74 x 10(5) copies/mL (median 7.7 x 10(4) and CD4 counts 6 to 605 cells/dL (M = 247; 95% CI 198-295). Of 39 patients who completed 48 weeks of treatment, viral load suppression was attained in 31 patients (79.4%; 95% CI 66.8-92.0) at 24 weeks and in 27 patients (69.2%; 95% CI 54-83) at 48 weeks. The CD4 lymphocyte count increased in 32 (82%) patients (mean 106 cells/dL, 95% CI 73-139, p =.0001, Wilcoxon signed rank test) after 24 weeks and in 33 (84.6%) patients (mean 160 cells/dL, 95% CI 115-204, p =.0001, Wilcoxon signed rank test) after 48 weeks of treatment. Of 20 patients whose baseline viral load was <100000, 16 had viral load suppressed at 24 weeks and 15 at 48 weeks (p =.6, chi-square test).

CONCLUSION

A regime of nevirapine with two nucleoside analogues provided durable suppression of plasma viral load in HIV infected patients, with significant improvement in the CD4 cell count.

Opportunistic screening for genital chlamydial infection. I: acceptability of urine testing in primary and secondary healthcare settings

OBJECTIVES

To determine the acceptability of opportunistic screening for Chlamydia trachomatis in young people in a range of healthcare settings.

DESIGN

An opportunistic screening programme (1 September 1999 to 31 August 2000) using urine samples tested by ligase chain reaction (LCR). Data on uptake and testing were collected and in-depth interviews were used for programme evaluation.

SETTING

General practice, family planning, genitourinary medicine clinics, adolescent sexual health clinics, termination of pregnancy clinics, and women's services in hospitals (antenatal, colposcopy, gynaecology and infertility clinics) in two health authorities (Wirral and Portsmouth and South East Hampshire). Main participants: Sexually active women aged between 16 and 24 years attending healthcare settings for any reason.

MAIN OUTCOME MEASURES

Uptake data: proportion of women accepting a test by area, healthcare setting, and age; overall population coverage achieved in 1 year. Evaluation data: participants' attitudes and views towards opportunistic screening and urine testing.

RESULTS

Acceptance of testing by women (16-24 years) was 76% in Portsmouth and 84% in Wirral. Acceptance was lower in younger women (Portsmouth only) and varied by healthcare setting within each site. 50% of the target female population were screened in Portsmouth and 39% in Wirral. Both the opportunistic offer of screening and the method of screening were universally acceptable. Major factors influencing a decision to accept screening were the non-invasive nature of testing and treatment, desire to protect future fertility, and the experimental nature of the screening programme.

CONCLUSIONS

An opportunistic model of urine screening for chlamydial infection is a practical, universally acceptable method of screening.

Opportunistic screening for genital chlamydial infection. II: prevalence among healthcare attenders, outcome, and evaluation of positive cases

OBJECTIVES

To determine the prevalence and treatment outcomes among young women screened opportunistically for genital Chlamydia trachomatis and to evaluate the impact of screening in those participating.

DESIGN

An opportunistic screening programme (1 September 1999 to 31 August 2000) using urine samples, tested by ligase chain reaction (LCR). In-depth interviews were used for programme evaluation.

SETTING

Screening was offered in two health authorities at general practice, family planning, genitourinary medicine (GUM), adolescent sexual health, termination of pregnancy clinics and women's services in hospitals (antenatal, colposcopy, gynaecology and infertility clinics). Main participants: Sexually active women (16-24 years) attending for any reason.

MAIN OUTCOME MEASURES

Screening data: prevalence of infection by age and healthcare setting; proportion of positive patients attending for treatment. Evaluation data: participants' attitudes and views towards screening and follow up.

RESULTS

In total, 16 930 women (16-24 years) were screened. Prevalence was higher in younger women (16-20) than those aged 21-24 years and was highly variable at different healthcare settings (range 3.4%-17.6%). Prevalence was approximately 9% in general practice. The role of the project health advisers in managing results and coordinating treatment of positive individuals was essential; the vast majority of all positives were known to be treated. Women felt that screening was beneficial. Improving awareness and education about sexually transmitted infections is required to alleviate negative reactions associated with testing positive for infection.

CONCLUSIONS

Prevalence of infection outside GUM clinics is substantial and opportunistic screening using urine samples is an acceptable method of reaching individuals with infection who do not normally present at specialist clinics.

Using "the Japanese problem" as a corrective to the ethnocentricity of Western theory

This reflection on the essay by Rothbaum, Pott, Azuma, Miyake, and Weisz focuses on how knowledge about Japanese psychological development and culture can serve as a corrective to the ethnocentrism of Western theory. Particular attention is given to the Japanese cultural concepts of amae and kejime.

Interviewing preschoolers: comparisons of yes/no and wh- questions

This study investigated the influence of question format on preschool-aged children's errors, their response accuracy, and their tendency to say "I don't know" when given non-misleading questions in a neutral, unbiased context. Children (3 to 5 years old) participated in a craft-making session that included a staged "accident" with two experimenters differing in gender and appearance; the environment also had several distinctive features. One week later children were interviewed about actions, participants, and environment; questions were yes/no format with the veridical response "yes" ("yes" questions), yes/no format with the veridical response "no" ("no" questions), and specific wh- format questions. Question format substantially influenced children's responses: they were most likely to make errors if asked "no" questions, and were unlikely to answer either yes/no question with "I don't know." In contrast, children spontaneously and frequently said "I don't know" to wh- questions about content they did not recall (environment), but not about content that was well recalled (actions). Implications of question format for reliability of eyewitness testimony by preschoolers are discussed.

Muscle quality and age: cross-sectional and longitudinal comparisons

We addressed whether muscle quality (force per unit muscle mass) changes with age in cross-sectional and longitudinal analyses from three groups from the Baltimore Longitudinal Study of Aging: (1) Isometric arm strength studied cross-sectionally in 617 subjects with muscle mass estimated by cross-sectional area (CSA) from arm circumference and by 24-hour urinary creatinine excretion (CREAT); (2) longitudinal study for 10 to 25 years in 412 men using the same measures as the first group; and (3) isometric knee extensor strength studied cross-sectionally in 675 subjects; muscle mass estimated by CREAT, CSA from thigh circumference, and leg nonosseous fat free mass (FFM) from dual energy x-ray absorptiometry. Muscle quality declined in both arm and leg with age in cross-sectional analyses using CSA and FFM, but not CREAT. No age-associated arm muscle quality declines were observed longitudinally using CREAT or CSA. The relationship between muscle quality and age is dependent on how muscle mass is estimated and on whether subjects are studied cross-sectionally or longitudinally. In addition, CREAT may measure a muscle property not accounted for by CSA or FFM.

The relationship of peripheral motor nerve conduction velocity to age-associated loss of grip strength

Age-associated loss of muscle strength is attributed to decreasing muscle mass. Both strength and mass are dependent on peripheral innervation. However, the association between nerve function and age-associated strength loss has not been studied directly. The median nerve contribution to grip strength was estimated using nerve conduction velocity (NCV). Grip strength and NCV were measured in 197 male participants of the Baltimore Longitudinal Study of Aging (age 59.0 +/- 13.9 years). Multiple regression and path analyses were used separately to examine the association between median NCV and grip strength. Grip strength showed a negative quadratic relationship with increasing age (r2 = 0.32, p < 0.001) with a major change in slope occurring after 64.7 years of age. Median NCV (r2 = 0.14, p < 0.001) declined linearly with age. Median NCV significantly contributed to grip strength (p < 0.001) while controlling for forearm muscle mass (forearm circumference), self-reported 24-hour caloric expenditures, and age. The median nerve has an independent contribution to age-associated levels of muscle strength. The level of the effect was smaller than what could be attributed to forearm muscle mass or age.

Serum immunoreactive erythropoietin levels and associated factors amongst HIV-infected children

OBJECTIVES

To determine the spectrum of serum immunoreactive erythropoietin (SIE) levels amongst HIV-infected children aged < 13 years in relation to the levels among healthy children as well as those with renal failure; to examine the relationship between clinical and laboratory parameters and SIE levels.

DESIGN

A cross-sectional study with a descriptive non-interventional format. HIV-infected Canadian subjects were recruited through four tertiary Canadian and one Bahamian centre. Children with renal failure and healthy children were recruited from one of the Canadian centres.

METHODS

Study subjects had clinical and laboratory profiles determined at baseline and at each of five follow-up periods over 1 year. SIE levels were measured by radioimmunoassay with a normal range of 12-28 IU/I. Data handling and statistical functions were performed by the Canadian HIV Trials Network.

RESULTS

The study enrolled 133 HIV-infected subjects and 38 controls. Of these, 117 HIV-infected subjects, 24 healthy controls, and 11 controls with renal failure were eligible for analysis. The median age of infected subjects was 44 months, whereas that of healthy controls was 56 months, and 95 months for controls with renal failure. The median SIE levels were 14 and 11 IU/I for subjects with renal failure and healthy subjects, respectively. The median SIE level was 61 IU/I among zidovudine (ZDV)-treated subjects and 22 IU/I among ZDV-naive HIV-infected subjects. HIV-infected children almost invariably had SIE levels < 200 IU/I. The median SIE levels amongst HIV-infected subjects whose hemoglobin levels were < 100 g/l were 98 and 31 IU/I for ZDV-treated and ZDV-naive subjects, respectively (P = 0.002). This difference in median SIE levels between ZDV-treated subjects and ZDV-naive subjects was also observed among subjects whose hemoglobin levels were > 100 g/l (median, 58 and 15 IU/l, respectively; P < 0.001). Hemoglobin level was the most important predictor of log10 SIE (P < 0.01 for ZDV-treated and ZDV-naive subjects).

CONCLUSIONS

SIE levels amongst HIV-infected children were affected by HIV infection, use of ZDV, and presence or absence of anemia. SIE levels amongst HIV-infected children were generally lower than 200 IU/I. This characterization of SIE levels will facilitate clinical trials of exogenous recombinant human erythropoietin in HIV-infected children with anemia.

Spontaneous splenic rupture and infectious mononucleosis in a forensic setting

In this report we present two fatal cases of spontaneous splenic rupture. The prodromal symptoms, clinical presentations, autopsy findings and histologic findings are discussed, pertinent literature reviewed and the implication for the forensic pathologist stressed.

Oral hairy leukoplakia with ultrastructural evidence of Merkel-like cells in human tongue epithelium

The purpose of this investigation was to examine cells in the stratum basale and subjacent lamina propria of oral hairy leukoplakia (OHL) specimens for previously unreported morphological changes. Tongue biopsy specimens were obtained from ten HIV-positive and five healthy male patients and examined by light (LM) and transmission electron microscopy (TEM). Observations made during the investigation revealed the following: (1) LM comparisons of control and OHL specimens indicated that clear cells in the stratum basale ranged from 3 to 7 per 100 basal epithelial cells in healthy tongue mucosa vs. 6 to 15 in OHL. (2) Merkel-like cells were noted in the stratum basale of control biopsies from the dorsal-lateral tongue surface. However, the frequency of observation was so rare as to imply that their presence was an exception rather than the norm. (3) In contrast, Merkel-like cells in OHL specimens were commonly encountered, indicating a possible unique relationship to the pathology. (4) Merkel-like cells associated with OHL lesions were morphologically similar, in all respects, to that of control specimens except for the presence of large, membrane bound, dense granules that ranged in size from 150-300 nm. (5) All biopsies of OHL exhibited evidence of Epstein Barr virus in the stratum corneum and superficial layers of the stratum spinosum. (6) A mild inflammatory infiltrate associated with OHL specimens revealed cytopathic changes in fibroblasts that appeared related to the presence of lymphoid cell types; indicating a possible cytolytic lymphocyte-mediated degradation of antigen altered host cells.

Age and gender comparisons of muscle strength in 654 women and men aged 20-93 yr

To assess age and gender differences in muscle strength, isometric, concentric (Con), and eccentric (Ecc) peak torque was measured in the knee extensors at a slow (0.52 rad/s) and fast (3.14 rad/s) velocity in 654 subjects (346 men and 308 women, aged 20-93 yr) from the Baltimore Longitudinal Study of Aging. Regression analysis revealed significant (P < 0.001) age-related reductions in Con and Ecc peak torque for men and women at both velocities, but no differences were observed between the gender groups or velocities. Age explained losses in Con better than Ecc peak torque, accounting for 30% (Con) vs. 19% (Ecc) of the variance in men and 28% (Con) vs. 11% (Ecc) in women. To assess age and gender differences in the ability to store and utilize elastic energy, the stretch-shortening cycle was determined in a subset of subjects (n = 47). The older women (mean age = 70 yr) showed a significantly greater enhancement in the stretch-shortening cycle, compared with men of similar age (P < 0.01) and compared with younger men and women (each P < 0.05). Both men and women showed significant declines in muscle quality for Con peak torque (P < 0.01), but no gender differences were observed. Only the men showed a significant decline in muscle quality (P < 0.001) for Ecc peak torque. Thus both men and women experience age-related losses in isometric, Con, and Ecc knee extensor peak torque; however, age accounted for less of the variance in Ecc peak torque in women, and women tend to better preserve muscle quality with age for Ecc peak torque. In addition, older women have an enhanced capacity to store and utilize elastic energy compared with similarly aged men as well as with younger women and men.

Age-associated loss of power and strength in the upper extremities in women and men

Cross-sectional and longitudinal age-associated reductions in power and isometric strength are described for the upper extremities. Over a 25-year period, repeated measures were taken approximately every 2 years from men and women in the Baltimore Longitudinal Study of Aging (BLSA). The longitudinal measures covered an average 9.6 years, range 1-25 years for men and an average 4.6 years, range 1-8 years for women. Strength and power declined beginning by age 40 in both women and men. Thereafter, power declined about 10% more than strength in men, while no significant differences were found in women. Age had a statistically independent influence on strength and power measures after adjusting for gender, height, weight, caloric expenditure, and muscle mass. Twenty-five-year longitudinal analyses in men confirmed the declines observed cross-sectionally, while no changes were observed in women over the 4-5 years of longitudinal data available. Further longitudinal studies are needed to understand the relationships between strength and power losses with age in women. The differences between power and strength changes with age in men argue for the importance of factors other than strength affecting power.

Determining the cost of care through clinical pathways

Using the steps from the first approach, the costing of clinical pathways is useful to both the clinical and administrative teams. With knowledge of pathway cost, clinicians can plan cost-effective changes in the pathway or consider cost factors when deliberating on different approaches to care. Using the patient classification system to unbundle the nursing component and using the number of nursing hours per day of care provides an opportunity to describe the intensity of the pathway in its entirety, and by each day of care. One is provided with an opportunity to learn from the cost variances by reviewing the standardized costs for the pathway, and the actual cost of care of patients on the pathway provides an opportunity to learn from the cost variances. This learning, coupled with the clinical variance analysis, can suggest new opportunities for improving care and potential cost savings. Lastly, the cost associated with a pathway is useful knowledge in negotiating managed care contracts.$

Effects of single nightly injections of growth hormone-releasing hormone (GHRH 1-29) in healthy elderly men

Age-related reductions in growth hormone (GH) and insulin-like growth factor-I (IGF-I) may contribute to decreased muscle mass and strength in older persons. The relationship of this phenomenon to skeletal muscle bioenergetics has not been reported. We sought to determine whether administration of GH-releasing hormone (GHRH) would sustain increases in GH and IGF-I and improve skeletal muscle function and selected measures of body composition and metabolism. We measured GH secretion, muscle strength, muscle histology, and muscle energy metabolism by phosphorus nuclear magnetic resonance spectroscopy (31P-NMRS), body composition, and endocrine-metabolic functions before and after 6 weeks of treatment. Eleven healthy, ambulatory, non-obese men aged 64 to 76 years with low baseline IGF-I levels were treated at home as outpatients by nightly subcutaneous self-injections of 2 mg GHRH for 6 weeks. We measured GH levels in blood samples obtained every 20 minutes from 8:00 PM to 8:00 AM; AM serum levels of IGF-I, IGF binding protein-3 (IGFBP-3), and GH binding protein (GHBP); muscle strength; muscle histology; the normalized phosphocreatine abundance, PCr/[PCr + Pi], and intracellular pH in forearm muscle by NMRS during both sustained and ramped exercise; body composition by dual-energy x-ray absorptiometry (DEXA); lipid levels; and glucose, insulin, and GH levels during an oral glucose tolerance test (OGTT). GHRH treatment increased mean nocturnal GH release (P < .02), the area under the GH peak ([AUPGH] P < .006), and GH peak amplitude (P < .05), with no change in GH pulse frequency or in levels of IGF-I, IGFBP-3, or GHBP Two of six measures of muscle strength, upright row (P < .02) and shoulder press (P < .04), and a test of muscle endurance, abdominal crunch (P < .03), improved. GHRH treatment did not alter exercise-mediated changes in PCr/[PCr + Pi] or intracellular pH, but decreased or abolished significant relationships between changes in PCr/[PCr + Pi] or pH and indices of muscle strength. GHRH treatment did not change weight, body mass index, waist to hip ratio, DEXA measures of muscle and fat, muscle histology, glucose, insulin, or GH responses to OGTT, or lipids. No significant adverse effects were observed. These data suggest that single nightly doses of GHRH are less effective than multiple daily doses of GHRH in eliciting GH- and/or IGF-I-mediated effects. GHRH treatment may increase muscle strength, and it alters baseline relationships between muscle strength and muscle bioenergetics in a manner consistent with a reduced need for anaerobic metabolism during exercise. Thus, an optimized regimen of GHRH administration might attenuate some of the effects of aging on skeletal muscle function in older persons.

Acceleration of cheese ripening

The characteristic aroma, flavour and texture of cheese develop during ripening of the cheese curd through the action of numerous enzymes derived from the cheese milk, the coagulant, starter and non-starter bacteria. Ripening is a slow and consequently an expensive process that is not fully predictable or controllable. Consequently, there are economic and possibly technological incentives to accelerate ripening. The principal methods by which this may be achieved are: an elevated ripening temperature, modified starters, exogenous enzymes and cheese slurries. The advantages, limitations, technical feasibility and commercial potential of these methods are discussed and compared.