Feasibility of video observed therapy to support controller inhaler use among children in West Baltimore

OBJECTIVE

To assess feasibility of a novel video directly observed therapy (DOT)-based digital asthma program intended to support correct inhaled corticosteroid (ICS) use among children.

METHODS

We conducted a 60-day pilot study among patients 2-18 years attending a primary care clinic with prescribed ICS and sub-optimally controlled asthma (recent hospitalization, ICS nonadherence, frequent rescue inhaler use, therapy escalation, or Asthma Control Test <20). Participants used a mobile application to receive reminders, submit videos of ICS doses (video DOT), and receive asynchronous feedback on adherence and inhaler technique. We assessed enrollment, engagement, program metrics, and user experience; adherence and inhaler errors were secondary outcomes.

RESULTS

Of 26 eligible patients, 21 (81%) enrolled and submitted ≥1 video; median age was 11 years (8-15), 71% were male, 90% had Medicaid, and 62% experienced ≥1 exacerbation in the previous 6 months. Retention was 57% and 52% at week 5 and 8, respectively. Participants submitted 810 videos. Missed doses, inhaler errors (n = 247) and adherence issues (n = 107) prompted 543 communications; inadequate inspiration or holding breath were most common. Among 16 patients with engagement >7 days and >4 videos, median inhaler error rate (proportion of videos with ≥1 error) decreased from week 1 to week 2 (73% vs 8%, p ≤ 0.05) with median adherence >80%. Participants experienced the program as long, but easy to use; benefits included building routines, skill, and independence.

CONCLUSIONS

This pilot study suggests high program acceptability among our cohort. High engagement with improved inhaler technique over the first 14 days suggests shorter implementation.

Acute acidosis attenuates leucine stimulated signal transduction and protein synthesis in rat skeletal muscle

BACKGROUND

Critical illnesses are often complicated by acute metabolic acidosis, which if persistent, adversely affects outcome. Among the harmful effects that it might cause are impaired utilization of nutrients, increased proteolysis and depressed protein synthesis, leading to muscle wasting. As the amino acid leucine stimulates protein synthesis by activating mTOR signaling, we explored whether in acidosis, impaired leucine-stimulated signaling might be a contributor to the depressed protein synthesis.

METHODS

Male pair-fed rats were gavaged with NH4Cl (acidosis) or NaCl (control) for 2 days and then gavaged once with leucine and sacrificed 45 min later. Extensor digitorum longus muscles were isolated, incubated with or without leucine and protein synthesis measured. The anterior tibial muscle signaling was analysed by Western immunobloting.

RESULTS

Despite pair-feeding, acidotic rats lost body and muscle weight vs. controls. Moreover, leucine-induced protein synthesis in isolated muscle from acidotic rats was impaired. In-vivo, 45 min after an oral leucine load, anterior tibial muscle mTOR and 4E-BP1 phosphorylation increased significantly and comparably in control and acidotic rats. In contrast, leucine-stimulated phosphorylation of S6K1, a regulator of translation initiation and protein synthesis, was attenuated to approximately 56% of the control value (p < 0.05).

CONCLUSION

This study reveals that an acute metabolic acidosis impairs leucine-stimulated protein synthesis and activation of signaling downstream of mTOR at the level of S6K1. We propose that this S6K1 abnormality may account in part, for the resistance to leucine-stimulated muscle protein synthesis, and may thereby contribute to the impaired nutrient utilization and ultimately the muscle wasting that develops in acidosis.

Impact of maternal hepatitis B virus coinfection on mother-to-child transmission of HIV

OBJECTIVES

Despite high hepatitis B virus (HBV) endemicity in various resource-limited settings (RLSs), the impact of maternal HIV/HBV coinfection on infant health outcomes has not been defined. We aimed to assess the prevalence of HBV coinfection among HIV-infected pregnant women and its impact on HIV transmission and infant mortality.

METHODS

In this study, the seroprevalence of HBV coinfection was determined among HIV-infected pregnant women enrolled in the Six-Week Extended-Dose Nevirapine (SWEN) India trial. The impact of maternal HIV/HBV coinfection on mother-to-child transmission (MTCT) of HIV and infant mortality was assessed using univariate and multivariate logistic regression analysis.

RESULTS

Among 689 HIV-infected pregnant Indian women, 32 (4.6%) had HBV coinfection [95% confidence interval (CI) 3.4%, 5.3%]. HBV DNA was detectable in 18 (64%) of 28 HIV/HBV-coinfected women; the median HBV viral load was 155 copies/mL [interquartile range (IQR) < 51-6741 copies/mL]. Maternal HIV/HBV coinfection did not increase HIV transmission risk [adjusted odds ratio (aOR) 1.06; 95% CI 0.30, 3.66; P = 0.93]. Increased odds of all-cause infant mortality was noted (aOR 3.12; 95% CI 0.67, 14.57; P = 0.15), but was not statistically significant.

CONCLUSIONS

The prevalence of active maternal HBV coinfection in HIV-infected pregnant women in India was 4.6%. HIV/HBV coinfection was not independently associated with HIV transmission.

Leucine-stimulated mTOR signaling is partly attenuated in skeletal muscle of chronically uremic rats

The branched-chain amino acid leucine stimulates muscle protein synthesis in part by directly activating the mTOR signaling pathway. Furthermore, leucine, if given in conjunction with resistance exercise, enhances the exercise-induced mTOR signaling and protein synthesis. Here we tested whether leucine can activate the mTOR anabolic signaling pathway in uremia and whether it can enhance work overload (WO)-induced signaling through this pathway. Chronic kidney disease (CKD) and control rats were studied after 7 days of surgically induced unilateral plantaris muscle WO and a single leucine or saline load. In the basal state, 4E-BP1 phosphorylation was modestly depressed in non-WO muscle of CKD rats, whereas rpS6 phosphorylation was nearly completely suppressed. After oral leucine mTOR, S6K1 and rpS6 phosphorylation increased similarly in both groups, whereas the phospho-4E-BP1 response was modestly attenuated in CKD. WO alone activated the mTOR signaling pathway in control and CKD rats. In WO CKD, muscle leucine augmented mTOR and 4E-BP1 phosphorylation, but its effect on S6K1 phosphorylation was attenuated. Taken together, this study has established that the chronic uremic state impairs basal signaling through the mTOR anabolic pathway, an abnormality that may contribute to muscle wasting. However, despite this abnormality, leucine can stimulate this signaling pathway in CKD, although its effectiveness is partially attenuated, including in skeletal muscle undergoing sustained WO. Thus, although there is some resistance to leucine in CKD, the data suggest a potential role for leucine-rich supplements in the management of uremic muscle wasting.

Temporal control in a complex environment: An analysis of schedule-related behavior

Three experiments conducted in an automated ten-compartment chamber recorded collateral activities of rats reinforced for lever pressing on differential-reinforcement-of-low-rate schedules. In Experiment 1, the rate of lever pressing increased when stimulus support for collateral activities was removed, thus confirming earlier findings. However, there were no temporal or sequential patterns of collateral activities that predicted operant responding. In Experiment 2, the rate of lever pressing increased only if (a) access to all stimulus support for collateral activities was simultaneously prevented, and (b) the rat was forced to remain in the presence of the lever and food tray. The availability of any of the stimuli related to collateral activity was sufficient to keep lever-pressing rates from increasing. Experiment 3 examined collateral activities under a signaled differential-reinforcement-of-low-rate schedule. Preventing access to stimuli supporting collateral activities had little effect on stable lever pressing when the signal was maintained. When the signal was removed, collateral activities continued, but lever-pressing rates increased in three of the four rats and rates of food presentation declined in all rats. Hypotheses that collateral activities have (a) a timekeeping or discriminative function, or (b) directly inhibit operant responding were not supported. The results suggest that collateral activities may facilitate operant responding by simply removing the subject from the presence of reinforcement-related stimuli.

Bilateral subthalamic stimulation improves gait initiation in patients with Parkinson's disease

Impaired gait initiation is one of the typical sign of advanced Parkinson's disease (PD). This is the first study to examine quantitatively the effect of deep brain stimulation of the subthalamic nucleus on the performance of gait initiation for patients with advanced PD. A total of 11 patients after surgery of bilateral deep brain stimulation of the subthalamic nucleus (STN) were tested in both the deep brain stimulation (DBS) ON and OFF conditions and/or in both the medication ON (i.e., with the usual dosage of antiparkinsonian medications administered) and OFF (i.e., with the usual dosage of antiparkinsonian medications withheld) conditions. DBS had no effect on the onset of anticipatory postural adjustment (APA). The effect of DBS approached significant level for the onset of swing foot lifting, but reached significant level for the delay of swing foot lifting. DBS significantly increased the amplitude of the APA, amplitude of reactive shear forces on both feet, and amplitude of COP in both anterior-posterior and medial-lateral directions. It is concluded that DBS significantly improved the performance of patients with advanced PD in gait initiation.

Trunk rotational strength training for the management of adolescent idiopathic scoliosis (AIS)

Quantified trunk rotational strength training has shown promise as a non-operative management option for individuals with AIS. The purposes of our study are to test whether a quantified trunk rotational strength training protocol can increase trunk strength and stabilize or decrease curve size. Seven adolescents with AIS (5 female 2 male; mean 14 yrs +/- 2.6 yrs; mean Cobb 28 degrees +/- 6 degrees range 20 degrees -37 degrees) underwent four months of supervised trunk rotational strength training, and repeat strength test. Trunk strength in both directions increased significantly after training (p<0.05). Average Cobb angle decreased to 23 degrees +/- 11 degrees (range 6 degrees -35 degrees). Four individuals showed reduction (>5 degrees) in their original curve, and 3 remained the same (+/-5 degrees). The strength training protocol significantly increased isometric rotational strength and scoliosis was stabilized short term.

Comparison of isometric trunk rotational strength of adolescents with idiopathic scoliosis to healthy adolescents

Trunk rotational strength asymmetry has been suggested in adolescents with idiopathic scoliosis (IS), but is unconfirmed. The sitting isometric trunk rotational strength, at neutral and 18 degrees or 36 degrees of right or left pre-rotation, of a group of healthy adolescent females (CG), n=12, is compared with a group of female adolescents with IS (ISG), n= 14. Torque values were normalized to lean body weight. There is a significant weakness when rotating towards the concavity found in patients with AIS at the 36 lo (p 0.07 marginal), 18 lo (p<0.03) and neutral positions (p<0.02), with no side strength asymmetry found in a cohort of healthy adolescents without AIS.

Quantitative assessments of the effect of bilateral subthalamic stimulation on multiple aspects of sensorimotor function for patients with Parkinson's disease

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is effective for the treatment of advanced Parkinson's disease. Most studies have evaluated the effectiveness of DBS of the STN using clinical motor scores or simple timed tests of motor function. There have been few studies that quantitatively assessed the outcome of STN DBS using multiple testing paradigms. In the current study, 11 patients who had bilateral STN DBS were quantitatively evaluated under four conditions using gait, postural control, and gait initiation. The four conditions included the medication on/stimulation on (M_on/S_on), medication on/stimulation off (M_on/S_off), medication off/stimulation on (M_off/S_on), and medication off/stimulation off (M_off/S_off) conditions. DBS of the STN significantly increased walking speed with and without levodopa, but had no influence on the cadence. The addition of levodopa had a minimal additional effect on walking speed. The effect of STN DBS on gait initiation approached the significant level. The mean values of lateral body sway during quiet standing increased moderately with medication and/or DBS, but the changes were not statistically significant. Future studies need to determine whether or not there is a potential negative effect of STN DBS on the postural control.

The effects of ankle bracing on motion of the knee and the hip joint during trunk rotation tasks

BACKGROUND

The use of prophylactic ankle braces is common during athletic activities since the ankle is one of the most commonly injured joints. Past studies have focused on the effects of ankle braces on ankle movement restriction, preventing injuries, proprioception, balance and athletic performance. However, the influence of ankle restriction on other joints has not been studied. The constraint of ankle movement may lead to an increased loading on the knee joint, which could be a potential risk of knee injuries during athletic activities. The primary goal of the current study was to determine quantitatively the effect of an ankle brace on the knee axial rotation during two different trunk turning tasks.

METHODS

Ten healthy subjects performed trunk turning movements while standing on one leg: turning sideways to catch a ball and turning sideways to touch a target with the shoulder. The tasks were performed with and without an ankle brace worn on the supporting leg. The trunk axial rotation in reference to the floor and three dimensional joint angular motions of the ankle, knee and hip were determined.

FINDINGS

The use of an ankle brace resulted in reduced trunk axial rotation during the ball catching tasks, and increased knee axial rotation during the target touching tasks.

INTERPRETATION

The results of this study showed that the effect of the ankle brace on the knee axial rotation depended on the context of the tasks performed. Under situations that required forceful trunk turning movement while standing on a single leg, the ankle braces may cause an increase in the knee axial rotation indicating higher risk of knee injury.

Live broadcast of laparoscopic surgery to handheld computers

BACKGROUND

Thanks to advances in computer power and miniaturization technology, portable electronic devices are now being used to assist physicians with various applications that extend far beyond Web browsing or sending e-mail. Handheld computers are used for electronic medical records, billing, coding, and to enable convenient access to electronic journals for reference purposes. The results of diagnostic investigations, such as laboratory results, study reports, and still radiographic pictures, can also be downloaded into portable devices for later view. Handheld computer technology, combined with wireless protocols and streaming video technology, has the added potential to become a powerful educational tool for medical students and residents. The purpose of this study was to assess the feasibility of transferring multimedia data in real time to a handheld computer via a wireless network and displaying them on the computer screens of clients at remote locations.

METHODS

A live laparoscopic splenectomy was transmitted live to eight handheld computers simultaneously through our institution's wireless network.

RESULTS

All eight viewers were able to view the procedure and to hear the surgeon's comments throughout the entire duration of the operation.

CONCLUSION

Handheld computer technology can play a key role in surgical education by delivering information to surgical residents or students when they are geographically distant from the actual event. Validation of this new technology by conducting clinical research is still needed to determine whether resident physicians or medical students can benefit from the use of handheld computers.

Wireless vital sign telemetry to hand held computers

Most physicians and other health care providers share/access patient information via hard copy chart records, telephone conversations, or through hospital computer networks. These modalities are cumbersome when physicians are away from the hospital and ground wiring infrastructure is not readily available. In a prior study, we used wireless in-flight telephony and the Internet to transmit vital signs from an airborne Boeing 757 to three remote locations on the ground. However, because all recipient stations relied on an institutional network to receive the information, it was not possible to transfer data to a given location beyond the hospital campus. We now propose an innovative system capable of transmitting telemetry information from any location in the globe to a single portable computer using Wireless Application Protocol (WAP) technology for the Internet. Medical data including blood pressure, pulse, respiratory rate, end tidal CO2, oxygen saturation and EKG tracings were transferred from a G2 (digital cellular) phone linked to a hand held computer to a remote hand held device and were viewed in real time using customized software. Cellular Digital Packet Protocols (CDPD) enabled data transfer speeds up to 19,200 bps. Advances including the Internet and wireless computer technology may revolutionize the way medical information is shared, making it possible for physicians and health allies to directly access patient data from anywhere at any time.

Differences between self- and peer ratings of interpersonal problems

Interpersonal problems are frequently a source of distress for individuals and the focus of psychotherapeutic interventions. A self-report circumplex measure, the Inventory of Interpersonal Problems Circumplex (IIP-C), was modified for this investigation to acquire peer report data on interpersonal problems to help assess the validity of self-reported problems. The peer report data replicated the circumplex model of the IIP-C and when general interpersonal distress was removed (by ipsatizing), the data suggested that peers observed more domineering, vindictive, and emotionally cold types of problems than self-report (ipsatized) data. Individuals reported more other-pleasing, overly nurturant types of problems than peers observed. The findings both support the validity of the IIP-C and describe discrepancies in self- versus peer reported interpersonal problems. The results also describe differences in the general interpersonal distress factor accounted for by ipsatizing versus removing the general factor from unipsatized data. The results describe implications for clinicians and others assessing interpersonal problems.