App-based intervention for cardiovascular and diabetes risk awareness and prevention

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Centre for Primary Health Care and Equity, University of New South WalesAustralian e-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation

Background

Cardiovascular disease and type 2 diabetes mellitus are highly prevalent worldwide. They have similar risk factors, and people with diabetes have a two- to threefold increased risk of myocardial infarction and stroke. Many of the risk factors are lifestyle related. Hence, behaviour change interventions have the potential to decrease the risk for cardiovascular disease and type 2 diabetes mellitus.

Purpose

We aimed to develop and evaluate an app-based intervention for the primary prevention of cardiovascular disease and type 2 diabetes mellitus.

Methods

We developed our app using the methodology by Tombor and colleagues for the development of digital behaviour change interventions. We used the Behaviour Change Wheel and embedded 12 behaviour change techniques. The three core modules of the app consisted of i) risk scores for 5-year cardiovascular disease and type 2 diabetes mellitus; ii) goal setting and tracking functions for smoking, alcohol intake, diet, and physical activity; and iii) education about the diseases and risk factors. With the app prototype, we conducted usability testing via an iterative approach. We interviewed the participants and used their feedback to improve the app design. Next, we conducted a feasibility study with the new version to assess whether participants would use the app over three months. We were interested in drop-out from the intervention, adherence to app use, and usability of the app. We received ethics approval for both studies and written consent from all participants.

Results

The usability testing consisted of two rounds. For each round, we had five participants who were on average 57 years old. In the first round, three participants experienced a technical error that stopped them from completing the registration. From those who were able to register, five rated the app as above average according to the System Usability Scale. Overall, the participants found the app easy to use and indicated that they were interested to use it frequently. We included some additional features based on the preferences of the participants in the usability testing. For the feasibility study, we recruited 47 participants aged 45 years and older who were free of cardiovascular disease and type 2 diabetes mellitus at baseline, with a balanced distribution of age (45-64 years and ≥65 years) and gender. From those participants, four withdrew from the study immediately after providing consent and the remainder continued using the app for varying periods of time.

Conclusions

We ensured that the app is based on the theory of behaviour change and scientific evidence. We used a stepwise approach to improve the app design and to test the feasibility of the intervention. The next step will be to develop a framework for a larger trial that implements the intervention into the existing healthcare setting and investigates its effectiveness.

Standardizing resolution definition in scanning helium microscopy

Resolution is a key parameter for microscopy, but methods for standardizing its definition are often poorly defined. For a developing technique such as scanning helium microscopy, it is critical that a consensus-based protocol for determining instrument resolution is prepared as a written standard to allow both comparable quantitative measurements of surface topography and direct comparisons between different instruments. In this paper we assess a range of quantitative methods for determining instrument resolution and determine their relative merits when applied to the specific case of the scanning helium microscope (SHeM). Consequently, we present a preliminary protocol for measuring the resolution in scanning helium microscopy based upon utilizing appropriate test samples with sets of slits of well-defined dimensions to establish the quantitative resolution of any similar instrument.

Observation of diffuse scattering in scanning helium microscopy

By studying well defined geometries (microspheres) in scanning helium microscopy (SHeM) the default scattering distribution for technological surfaces in SHeM is found to be diffuse and approximately cosine.

Image formation in the scanning helium microscope

The scanning helium microscope (SHeM) is a new addition to the array of available microscopies, particularly for delicate materials that may suffer damage under techniques utilising light or charged particles. As with all other microscopies, the specifics of image formation within the instrument are required to gain a full understanding of the produced micrographs. We present work detailing the basics of the subject for the SHeM, including the specific nature of the projection distortions that arise due to the scattering geometry. Extension of these concepts allowed for an iterative ray tracing Monte Carlo model replicating diffuse scattering from a sample surface to be constructed. Comparisons between experimental data and simulations yielded a minimum resolvable step height of (67 ± 5) µm and a minimum resolvable planar angle of (4.3 ± 0.3)° for the instrument in question.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Kids in space: Measuring children's residential neighborhoods and other destinations using activity space GPS and wearable camera data

INTRODUCTION

Defining the boundary of children's 'neighborhoods' has important implications for understanding the contextual influences on child health. Additionally, insight into activities that occur outside people's neighborhoods may indicate exposures that place-based studies cannot detect. This study aimed to 1) extend current neighborhood research, using data from wearable cameras and GPS devices that were worn over several days in an urban setting; 2) define the boundary of children's neighborhoods by using leisure time activity space data; and 3) determine the destinations visited by children in their leisure time, outside their neighborhoods.

METHOD

One hundred and fourteen children (mean age 12y) from Wellington, New Zealand wore wearable cameras and GPS recorders. Residential Euclidean buffers at incremental distances were paired with GPS data (thereby identifying time spent in different places) to explore alternative definitions of neighborhood boundaries. Children's neighborhood boundary was at 500 m. A newly developed software application was used to identify 'destinations' visited outside the neighborhood by specifying space-time parameters. Image data from wearable cameras were used to determine the type of destination.

RESULTS

Children spent over half of their leisure time within 500 m of their homes. Children left their neighborhood predominantly to visit school (for leisure purposes), other residential locations (e.g. to visit friends) and food retail outlets (e.g. convenience stores, fast food outlets). Children spent more time at food retail outlets than at structured sport and in outdoor recreation locations combined.

CONCLUSION

Person-centered neighborhood definitions may serve to better represent children's everyday experiences and neighborhood exposures than previous methods based on place-based measures. As schools and other residential locations (friends and family) are important destinations outside the neighborhood, such destinations should be taken into account. The combination of image data and activity space GPS data provides a more robust approach to understanding children's neighborhoods and activity spaces.

A simple counter-flow cooling system for a supersonic free-jet beam source assembly

A simple design for an inexpensive, cooled, free-jet beam source is described. The source assembly features an integrated cooling system as supplied by a counter-flow of chilled nitrogen, and is composed primarily of off-the-shelf tube fittings. The design facilitates rapid implementation and eases subsequent alignment with respect to any downstream beamline aperture. The source assembly outlined cools the full length of the stagnation volume, offering temperature control down to 100 K and long-term temperature stability better than ±1 K.

Unlocking new contrast in a scanning helium microscope

Delicate structures (such as biological samples, organic films for polymer electronics and adsorbate layers) suffer degradation under the energetic probes of traditional microscopies. Furthermore, the charged nature of these probes presents difficulties when imaging with electric or magnetic fields, or for insulating materials where the addition of a conductive coating is not desirable. Scanning helium microscopy is able to image such structures completely non-destructively by taking advantage of a neutral helium beam as a chemically, electrically and magnetically inert probe of the sample surface. Here we present scanning helium micrographs demonstrating image contrast arising from a range of mechanisms including, for the first time, chemical contrast observed from a series of metal–semiconductor interfaces. The ability of scanning helium microscopy to distinguish between materials without the risk of damage makes it ideal for investigating a wide range of systems.

Scanning helium microscopy uses neutral atoms to image traditionally challenging materials (e.g. delicate, insulating and magnetic samples) non-destructively with absolute surface sensitivity. This work reports the first observation of chemical contrast in helium microscopy via inelastic scattering.

A highly contrasting scanning helium microscope

We present a scanning helium microscope equipped to make use of the unique contrast mechanisms, surface sensitivity, and zero damage imaging the technique affords. The new design delivers an order of magnitude increase in the available helium signal, yielding a higher contrast and signal-to-noise ratio. These improvements allow the microscope to produce high quality, intuitive images of samples using topological contrast, while setting the stage for investigations into further contrast mechanisms.

Guidelines on the use of extracorporeal photopheresis

BACKGROUND

After the first investigational study on the use of extracorporeal photopheresis for the treatment of cutaneous T-cell lymphoma was published in 1983 with its subsequent recognition by the FDA for its refractory forms, the technology has shown significant promise in the treatment of other severe and refractory conditions in a multi-disciplinary setting. Among the major studied conditions are graft versus host disease after allogeneic bone marrow transplantation, systemic sclerosis, solid organ transplant rejection and inflammatory bowel disease.

MATERIALS AND METHODS

In order to provide recognized expert practical guidelines for the use of this technology for all indications the European Dermatology Forum (EDF) proceeded to address these questions in the hands of the recognized experts within and outside the field of dermatology. This was done using the recognized and approved guidelines of EDF for this task.

RESULTS AND CONCLUSION

These guidelines provide at present the most comprehensive available expert recommendations for the use of extracorporeal photopheresis based on the available published literature and expert consensus opinion.

PD-L1 Expression in Clear Cell Renal Cell Carcinoma: An Analysis of Nephrectomy and Sites of Metastases

Background: Expression of programmed death ligand (PD-L1/B7-H1/CD274) represents a mechanism of immune escape for renal cell carcinoma (RCC) cells. Drugs blocking PD-L1 or its receptor are in clinical development and early data suggests that tumor PD-L1 expression may predict response.

Patients and Methods: A tissue microarray (TMA) consisting of four biopsy cores from 34 matched pairs of nephrectomy and metastatic sites of clear cell RCC was used to assess PD-L1 expression by quantitative immunofluorescence. Assessment of intra- and inter-tumor heterogeneity and primary and metastatic tumor expression was performed using a method of Automated Quantitative Analysis (AQUA).

Results: The median AQUA scores were higher in metastatic than primary specimens (P < 0.0001). The correlation between PD-L1 expression in matched primary and metastatic specimens was weak (R= 0.24). Within a given tumor, variable PD-L1 staining heterogeneity was seen, however the degree of heterogeneity was similar in primary and metastatic sites (P = 0.482).

Conclusions: The weak correlation between PD-L1 expression in primary and metastatic sites for a given patient suggests that expression in nephrectomy specimens cannot be used to select metastatic RCC patients for PD-L1 and PD-1 inhibitors. The intra-tumor heterogeneity seen in both primary and metastatic specimens indicates that a single core biopsy might not be sufficient to determine PD-L1 expression.

Acquired differential regulation of caspase-8 in cisplatin-resistant non-small-cell lung cancer

Failure to efficiently induce apoptosis contributes to cisplatin resistance in non-small-cell lung cancer (NSCLC). Although BCL-2-associated X protein (BAX) and BCL-2 antagonist killer (BAK) are critical regulators of the mitochondrial apoptosis pathway, their requirement has not been robustly established in relation to cisplatin. Here, we show that cisplatin can efficiently bypass mitochondrial apoptosis block caused by loss of BAX and BAK, via activation of the extrinsic death receptor pathway in some model cell lines. Apoptosis resistance following cisplatin can only be observed when both extrinsic and intrinsic pathways are blocked, consistent with redundancy between mitochondrial and death receptor pathways in cisplatin-induced apoptosis. In H460 NSCLC cells, caspase-8 cleavage was shown to be induced by cisplatin and is dependent on death receptor 4, death receptor 5, Fas-associated protein with death domain, acid sphingomyelinase and ceramide synthesis. In contrast, cisplatin-resistant cells fail to activate caspase-8 via this pathway despite conserving sensitivity to death ligand-driven activation. Accordingly, caspase-8 activation block acquired during cisplatin resistance, can be bypassed by death receptor agonism.

Identifying the barriers and facilitators to participation in physical activity for children with Down syndrome

BACKGROUND

Many children with Down syndrome do not undertake the recommended amount of daily physical activity. The aim of this study was to explore the barriers and facilitators to physical activity for this group.

METHODS

Eighteen in-depth interviews were conducted with 20 parents (16 mothers, 4 fathers) of children with Down syndrome aged between 2 and 17 years to examine what factors facilitate physical activity and what factors are barriers to activity for their children. The participants were recruited through a community disability organisation that advocates for people with Down syndrome and their families. Interviews were recorded, transcribed and independently coded and analysed by two researchers using thematic analysis.

RESULTS

Four themes on facilitators of physical activity were identified: (1) the positive role of the family; (2) opportunity for social interaction with peers; (3) structured accessible programmes that make adaptations for children with Down syndrome; and (4) children who were determined to succeed and physically skilled. Four themes on the barriers to physical activity were also identified: (1) characteristics commonly associated with Down syndrome; (2) competing family responsibilities; (3) reduced physical or behavioural skills; and (4) a lack of accessible programmes.

CONCLUSIONS

The results highlight the important role of families in determining how much physical activity children with Down syndrome undertake and the effect that common characteristics associated with Down syndrome can have on maintaining an active lifestyle. Future research needs to concentrate on successful methods of encouraging physical activity, such as ensuring social interaction is part of the activity, and eliminating barriers to physical activity such as the a lack of appropriate programmes for children with Down syndrome. Implementing these strategies may encourage children with Down syndrome to participate more frequently in a physically active lifestyle.

Omeprazole induces gastric permeability to digoxin

Previous animal and patient-based studies have shown that omeprazole induces a transepithelial paracellular gastric leak. This study reports on the potential for an omeprazole-induced leak of drugs with narrow therapeutic windows. Ussing chamber experiments investigated the effects of omeprazole on rat gastric corpus permeability to the drugs, digoxin and phenytoin. Digoxin (780 MW) permeated the gastric mucosa at an accelerated rate in the presence of omeprazole. This leak could contribute to dangerous elevations of blood digoxin levels in certain situations. Omeprazole was found to have no effect on the flux rate of phenytoin (252 MW). The tight-junctional leak generated by omeprazole thus exhibits specificity to the types of molecules it allows to permeate through the gastric mucosa. This leak may pose a clinical danger by increasing drug uptake into the bloodstream, a phenomenon which would act synergistically with the effect of omeprazole on inhibiting liver cytochrome P450s that remove drugs from the bloodstream, thereby elevating drug blood levels.

Effects of genetic variation in the aldosterone synthase (CYP11B2) gene on enzyme function

OBJECTIVE

Evidence suggests that high levels of aldosterone lead to hypertension and increased risk of cardiovascular disease. Around 15% of patients with essential hypertension have a raised aldosterone to renin ratio (ARR) suggesting that aldosterone production is inappropriately high in relation to its principal agonist angiotensin II. This may be due to increased activity of aldosterone synthase caused by genetic variation in the CYP11B2 gene. We screened the coding region of human CYP11B2 for genetic variants and tested their effects on function in vitro.

PROTOCOL

Normotensive subjects (n = 69) were screened for sequence variants in the coding region of CYP11B2 by single-stranded conformation polymorphism (SSCP) analysis and sequencing. The effects of nonsynonymous variants on enzyme activity were assessed in JEG-3 cells transiently transfected with wild-type or variant expression plasmids. The conversion of the substrate 11-deoxycorticosterone (DOC) to corticosterone (B) and aldosterone was measured.

RESULTS

Twenty variants were detected in CYP11B2 and eight analysed functionally (Arg87Gly, Asn281Thr, Gly288Ser, Lys296Asn, Asp335Asn, Gln404Arg, Ala414Pro and His439Tyr). Corticosterone synthesis was unaltered and aldosterone synthesis reduced in variant Arg87Gly; Asn281Thr increased corticosterone and decreased aldosterone production; Gly288Ser increased corticosterone production and abolished aldosterone production; Lys296Asn reduced both corticosterone and aldosterone production; Asp335Asn increased corticosterone synthesis but did not affect aldosterone production. Variants Gln404Arg, Ala414Pro and His439Tyr showed increases in both corticosterone and aldosterone synthesis compared to the wild-type.

CONCLUSION

The study confirms the genetic variability of the CYP11B2 gene and provides us with additional valuable structure-function information.