Patient, caregiver and other knowledge user engagement in consensus-building healthcare initiatives: a scoping review protocol

INTRODUCTION

Patient engagement and integrated knowledge translation (iKT) processes improve health outcomes and care experiences through meaningful partnerships in consensus-building initiatives and research. Consensus-building is essential for engaging a diverse group of experienced knowledge users in co-developing and supporting a solution where none readily exists or is less optimal. Patients and caregivers provide invaluable insights for building consensus in decision-making around healthcare, policy and research. However, despite emerging evidence, patient engagement remains sparse within consensus-building initiatives. Specifically, our research has identified a lack of opportunity for youth living with chronic health conditions and their caregivers to participate in developing consensus on indicators/benchmarks for transition into adult care. To bridge this gap and inform our consensus-building approach with youth/caregivers, this scoping review will synthesise the extent of the literature on patient and other knowledge user engagement in consensus-building healthcare initiatives.

METHODS AND ANALYSIS

Following the scoping review methodology from Joanna Briggs Institute, published literature will be searched in MEDLINE, EMBASE, CINAHL and PsycINFO databases from inception to July 2023. Grey literature will be hand-searched. Two independent reviewers will determine the eligibility of articles in a two-stage process, with disagreements resolved by a third reviewer. Included studies must be consensus-building studies within the healthcare context that involve patient engagement strategies. Data from eligible studies will be extracted and charted on a standardised form. Abstracted data will be analysed quantitatively and descriptively, according to specific consensus methodologies, and patient engagement models and/or strategies.

ETHICS AND DISSEMINATION

Ethics approval is not required for this scoping review protocol. The review process and findings will be shared with and informed by relevant knowledge users. Dissemination of findings will also include peer-reviewed publications and conference presentations. The results will offer new insights for supporting patient engagement in consensus-building healthcare initiatives.

PROTOCOL REGISTRATION

https://osf.io/beqjr.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Severe Respiratory Disease Among Children With and Without Medical Complexity During the COVID-19 Pandemic

Importance

Severe respiratory disease declined during the COVID-19 pandemic, partially due to decreased circulation of respiratory pathogens. However, the outcomes of children with higher risk have not been described using population-based data.

Objective

To compare respiratory-related hospitalizations, intensive care unit (ICU) admissions, and mortality during the pandemic vs prepandemic, among children with medical complexity (CMC) and without medical complexity (non-CMC).

Design, Setting, and Participants

This population-based repeated cross-sectional study used Canadian health administrative data of children aged younger than 18 years in community and pediatric hospitals during a pandemic period (April 1, 2020, to February 28, 2022) compared with a 3-year prepandemic period (April 1, 2017, to March 31, 2020). The pandemic period was analyzed separately for year 1 (April 1, 2020, to March 31, 2021) and year 2 (April 1, 2021, to February 28, 2022). Statistical analysis was performed from October 2022 to April 2023.

Main Outcomes and Measures

Respiratory-related hospitalizations, ICU admissions, and mortality before and during the pandemic among CMC and non-CMC.

Results

A total of 139 078 respiratory hospitalizations (29 461 respiratory hospitalizations for CMC and 109 617 for non-CMC) occurred during the study period. Among CMC, there were fewer respiratory hospitalizations in both 2020 (rate ratio [RR], 0.44 [95% CI, 0.42-0.46]) and 2021 (RR, 0.55 [95% CI, 0.51-0.62]) compared with the prepandemic period. Among non-CMC, there was an even larger relative reduction in respiratory hospitalizations in 2020 (RR, 0.18 [95% CI, 0.17-0.19]) and a similar reduction in 2021 (RR, 0.55 [95% CI, 0.54-0.56]), compared with the prepandemic period. Reductions in ICU admissions for respiratory illness followed a similar pattern for CMC (2020: RR, 0.56 [95% CI, 0.53-0.59]; 2021: RR, 0.66 [95% CI, 0.63-0.70]) and non-CMC (2020: RR, 0.22 [95% CI, 0.20-0.24]; RR, 0.65 [95% CI, 0.61-0.69]). In-hospital mortality for these conditions decreased among CMC in both 2020 (RR, 0.63 [95% CI, 0.51-0.77]) and 2021 (RR, 0.72 [95% CI, 0.59-0.87]).

Conclusions and Relevance

This cross-sectional study found a substantial decrease in severe respiratory disease resulting in hospitalizations, ICU admissions, and mortality during the first 2 years of the pandemic compared with the 3 prepandemic years. These findings suggest that future evaluations of the effect of public health interventions aimed at reducing circulating respiratory pathogens during nonpandemic periods of increased respiratory illness may be warranted.

Effectiveness of Structured Care Coordination for Children With Medical Complexity: The Complex Care for Kids Ontario (CCKO) Randomized Clinical Trial

Importance

Children with medical complexity (CMC) have chronic conditions and high health needs and may experience fragmented care.

Objective

To compare the effectiveness of a structured complex care program, Complex Care for Kids Ontario (CCKO), with usual care.

Design, Setting, and Participants

This randomized clinical trial used a waitlist variation for randomizing patients from 12 complex care clinics in Ontario, Canada, over 2 years. The study was conducted from December 2016 to June 2021. Participants were identified based on complex care clinic referral and randomly allocated into an intervention group, seen at the next available clinic appointment, or a control group that was placed on a waitlist to receive the intervention after 12 months.

Intervention

Assignment of a nurse practitioner-pediatrician dyad partnering with families in a structured complex care clinic to provide intensive care coordination and comprehensive plans of care.

Main Outcomes and Measures

Co-primary outcomes, assessed at baseline and at 6, 12, and 24 months postrandomization, were service delivery indicators from the Family Experiences With Coordination of Care that scored (1) coordination of care among health care professionals, (2) coordination of care between health care professionals and families, and (3) utility of care planning tools. Secondary outcomes included child and parent health outcomes and child health care system utilization and cost.

Results

Of 144 participants randomized, 141 had complete health administrative data, and 139 had complete baseline surveys. The median (IQR) age of the participants was 29 months (9-102); 83 (60%) were male. At 12 months, scores for utility of care planning tools improved in the intervention group compared with the waitlist group (adjusted odds ratio, 9.3; 95% CI, 3.9-21.9; P < .001), with no difference between groups for the other 2 co-primary outcomes. There were no group differences for secondary outcomes of child outcomes, parent outcomes, and health care system utilization and cost. At 24 months, when both groups were receiving the intervention, no primary outcome differences were observed. Total health care costs in the second year were lower for the intervention group (median, CAD$17 891; IQR, 6098-61 346; vs CAD$37 524; IQR, 9338-119 547 [US $13 415; IQR, 4572-45 998; vs US $28 136; IQR, 7002-89 637]; P = .01).

Conclusions and Relevance

The CCKO program improved the perceived utility of care planning tools but not other outcomes at 1 year. Extended evaluation periods may be helpful in assessing pediatric complex care interventions.

Trial Registration

ClinicalTrials.gov Identifier: NCT02928757.

Integrated full-scale solar CPC/UV-LED–filtration system as a tertiary treatment in a conventional WWTP for agricultural reuse purposes

Today, the emergence of increasingly restrictive treatment and reuse policies make the implementation of full-scale tertiary treatment, capable of improving the quality of water, a priority. Full-scale TiO2 photocatalysis systems are resulting in a promising option, since TiO2 is commercially available. However, questions such as how to work continuously during day/night irradiation cycle, or the removing of TiO2 in outlet flow are still unresolved. In this work, a full-scale system integrating a solar CPC/UV-LED step combined with commercial microfiltration membranes was installed in a conventional WWTP for agricultural reuse purposes. After optimization, 0.5 g/L of catalyst and combined SOLAR + UV-LED showing the highest pharmaceutical removal percentages, while a self-designed UV-LED included in the own reaction tank resulting in higher efficiencies compared with commercial lamps. Longer membrane surface area decreased fouling problems in the system. However, 60 min of irradiation time was necessary to reach the most restrictive water quality values according with (EU 2020/741). After optimization step, total costs were reduced by 45%. However, it was shown that a reduction in operating and maintenance costs, along with the development of more effective and economical commercial filtration membranes is a key factor; therefore, working on these aspects is essential in the treated water cost reduction.

Graphical abstract

Flow-status and survival in severe aortic stenosis treated with TAVI – is flow rate superior to stroke volume index?

Background

Low-flow status, currently defined as a stroke volume index (SVi) &lt;35 mL/m2, is an important prognostic predictor for mortality after Transcatheter Aortic Valve Implantation (TAVI) for severe aortic stenosis (SAS). However, transaortic flow rate (FR) – defined as stroke volume divided by left ventricle ejection time - has recently been suggested to be superior to SVi in defining low-flow states, as it reflects more closely valvular resistance, while being independent of body surface area. Low FR is most consistently defined as FR&lt;200 mL/s.

Purpose

Determine the prognostic impact of FR and SVi before TAVI in survival after intervention for SAS.

Methods

A single-centre retrospective database of all TAVI performed between 2011 and 2019 was analyzed, and cases with pre-intervention echocardiograms available were included. Low-flow patients were identified according to basal FR (&lt;200 mL/s) or SVi (&lt;35 mL/m2), and compared with normal-flow cases. The primary endpoint was defined as time to all-cause death or last follow-up. The impact of flow-status (using FR or SVi) in survival was assessed using Kaplan-Meier curves and log-rank test, as well as Cox proportional hazard model adjusted for EuroSCORE II, using FR or SVi either as categorical or continuous variables. A subanalysis further compared patients with preserved and reduced ejection fraction (EF, &lt;52%). p&lt;0.05 was considered statistically significant.

Results

From 657 TAVI performed, 490 (74.6%) cases were included, with a median follow-up of 43 months. From those, 59.6% were defined as low-flow according to FR, and 43.3% using SVi. Low-flow patients, using each parameter, were of higher surgical risk (EuroSCORE II and STS scores), had more advanced NYHA classes, worse estimated creatinine clearance, and suffered more frequently from coronary artery disease. Low-FR patients were also older, and more predominantly female. Atrial fibrillation was more prevalent among low SVi cases. Functional aortic valve area was lower in low-flow patients using both assessments, but low-SVi was also associated with lower transaortic gradients, as well as lower EF before and after TAVI. Regarding all-cause mortality, low-SVi was associated with worse survival [p=0.02, hazard ratio (HR) 1.43 (1.05–1.94)], but not low-FR (p=0.4). However, low-SVi, when adjusted for EuroScore II, was no longer a predictor of all-cause mortality (p=0.08). When considering FR and SVi as continuous variables, a higher SVi (but not FR) was associated with better survival (HR 0.98, p=0.047) in multivariable analysis adjusted for EuroSCORE II. When stratifying according to preserved and reduced EF, both FR and SVi did not predict all-cause mortality.

Conclusions

Low-flow states are common in SAS population treated with TAVI, being frequently associated with worse symptoms and higher procedural risk. Low-SVi, but not low-FR, negatively impacts survival after intervention, representing a marker for prognosis after TAVI.

Funding Acknowledgement

Type of funding sources: None.

Predictors for NYHA recovery and 1-year mortality after mitral TEER

Background

Mitral regurgitation (MR) is the second-most frequent valvular heart disease in Europe and frequently aggravates heart failure (HF) symptoms. Mitral transcatheter-edge-to-edge repair (TEER) can be considered in eligible patients, for both primary (in inoperable cases) or secondary severe MR. However, intervention is not advised in severe comorbid patients in whom it is not expected to prolong survival for over 1 year.

Purpose

Evaluate characteristics associated with HF New York Heart Association (NYHA) class recovery, and one-year all-cause mortality after mitral TEER for severe MR.

Methods

All mitral TEER procedures for primary and secondary MR conducted in a single-centre between 2014 and 2020 were retrospectively analyzed. The primary endpoint was defined as a reduction of at least one NYHA class in the first month after intervention, and a secondary endpoint considered a recovery of at least two NYHA classes. Survival status 12 months after mitral TEER was also consulted. Clinical, echocardiographic and blood-analysis data were explored as characteristics associated with the endpoints defined, using Pearson's Chi-squared test, Wilcoxon rank sum test and Fisher's exact test, as appropriate. A p&lt;0.05 was considered statistically significant.

Results

From 103 mitral TEER procedures, 86 (83%) had full information about pre- and post-intervention NYHA class, as well as survival status at 12 months. There was a higher proportion of primary MR among NYHA non-responders (47% versus 25%, p=0.034), but no differences for secondary MR. Higher surgical risk patients (EuroSCORE II) tended to have exhibit more NYHA recovery, though not reaching statistical significance (p=0.068). Both a more advanced NYHA class at baseline and lower N-terminal pro-brain natriuretic peptide (NTproBNP) levels were linked to a higher symptomatic recovery (2048 versus 5676pg/ml, p&lt;0.001). Also, persisting MR after TEER of at least grade 3/4 was more frequent in non-NYHA responders. Regarding NYHA improvement of at least two classes, it was observed in 13% patients, and these also had a more advanced NYHA class at baseline and lower NTproBNP basal levels, and exhibited a lower estimated systolic pulmonary artery pressure and inferior vena cava (IVC) diameter. Finally, 10 (11.6%) of mitral TEER patients died in the first 12 months, and no statistically significant associations were found regarding pre-intervention characteristics and survival.

Conclusions

This study suggests that three-fifths of severe MR improve their NYHA class after TEER, but only one-fourth for primary MR. Earlier intervention – with lower NTproBNP levels, less severe pulmonary hypertension, and lower IVC diameters – is associated with more symptomatic HF improvement. All-cause mortality in the first year is still significant, exposing a need for better patient selection. However, these findings represent exploratory deductions of a relatively low number, single-centre, patients.

Funding Acknowledgement

Type of funding sources: None.

Modeling aortic stenosis progression: impact on follow-up, treatment and survival

Background

Aortic stenosis (AS) is one of the main valvular heart diseases in developed countries. Degenerative fibrocalcific aortic stenosis is a progressive disease of the valve and ultimately of the myocardium, which can be fatal when symptomatic. There is no medical treatment that can halt or delay its progression. AS does not evolve linearly over time, and not every patient has the same progression rate.

Aims

The aim of this study is to 1) compare different mathematical models of aortic stenosis progression, 2) cluster patients into rapid and slow progressors and explore possible predictors, 4) evaluate the impact of different progression rates on cardiac structure and function, and 5) evaluate survival and optimal timing for follow-up and treatment.

Methods

We retrospectively studied consecutive patients with aortic peak velocities from 2012 to 2020. Follow-up echocardiograms, seriated biomarker assessment, and clinical records were consulted, providing a multiparametric data frame for longitudinal and dynamic modeling of aortic stenosis progression and its consequences.

Results

This study included 9583 studies from 752 patients with a median total follow-up of 4.26 years (interquartile range: 1.28 to 7.24 years). A logistic model was selected with the best accuracy to predict the rate of AS progression. Patients were categorized into slow and rapid progressors in a ratio of 5:1. Multiparametric analysis showed no association between these profiles and clinical variables. However, anti-hypertensive drugs before and after adjustment for blood pressure control (Calcium Channel Blockers, p=0.013, OR 0.50) were associated with slower progression. Meanwhile, elevated inflammatory markers (erythrocyte sedimentation rate, p=0.01) were associated with faster AS progression. Despite no survival difference between these groups, higher rates of valvular intervention were registered in rapid progressors (p&lt;0.001). Moreover, faster progressors were associated with earlier cardiac damage (as demonstrated by early onset of moderate mitral and tricuspid valve regurgitation, left auricle dilation, and left ventricle hypertrophy, p&lt;0.05).

Conclusions

These results can potentially modify follow-up times and deliver more personalized and individualized health care to different AS patients, thereby optimizing resources.

Funding Acknowledgement

Type of funding sources: None.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Role of epicardial adipose tissue volume as predictor of atrial fibrillation recurrence

Funding Acknowledgements

Type of funding sources: None.

Background

Several studies have demonstrated the relation between general obesity and atrial fibrillation (AF). Epicardial adipose tissue (EAT), due to its local paracrine effect and the intimate relation with the atrium, could influence AF recurrence rates, but very few studies have explored this association.

Purpose

In this study we aimed to evaluate if EAT could be a predictor of AF recurrence after an AF ablation procedure.

Methods

We included all consecutive patients submitted to AF ablation (2017-2019) who performed a computed tomography scan prior to the procedure. EAT volume was semi-automatically reconstructed by manually tracing the pericardium. Adipose tissue was defined in the range between -150 and -50 Hounsfield units. Recurrence was defined as any documented (ECG/Holter) episode of AF, atrial flutter or atrial tachycardia after 3 months of the procedure. Logistic regression with a restricted cubic polynomial transformation was used to model the non-linear relationship between recurrence and EAT volumes. Inspection of the partial effect curves suggested that a cutoff for EAT volume ≥80mL could stratify patients at risk of recurrence and a Time-to-event analysis was carried.

Results

A total of 354 patients (66% male, median age 57 years [IQR 48–65] and 21% persistent AF) were included. During a median follow-up of 34 months [IQR 24-43], 117 patients (33%) had AF recurrence. These patients had a significantly greater EAT volume (76 mL [IQR 55-111] vs 72 mL [IQR 48-95], p=0.03) when compared to those without recurrence. Also, patients with higher EAT volume (≥ 80mL) had a higher risk of recurrence compared to patients with lower volume (Figure 1, log-rank test p=0.007). After adjusting for clinical risk factors (age, gender, hypertension, diabetes mellitus, obesity, thyroid disease, AF type and left atrial enlargement), higher EAT volume did not remain an independent predictor of AF recurrence (Figure 2, HR 1.25 [95% CI, 0.83-1.86] p=0.3).

Conclusion

In this cohort of patients with AF submitted to catheter ablation, EAT volume ≥80mL was associated with increased risk of AF recurrence. However, it was not an independent predictor of AF recurrence after adjustment to clinical risk factors.

Higher coronary calcium score is associated with increased risk of atrial fibrillation recurrence

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with atrial fibrillation (AF) referred for catheter ablation routinely undergo cardiac computed tomography (CCT) for procedure planning. An opportunistic evaluation of coronary artery calcium score (CACS) can be an important tool to improve clinical care. It is already known that CACS is associated with a high risk of AF development, particularly if values are above 100, but few data are available regarding the impact of CACS in AF recurrence after ablation.

Purpose

To assess the impact of CACS on atrial fibrillation recurrence following catheter ablation.

Methods

Retrospective, single-centre cohort study of consecutive patients with AF undergoing CCT for ablation procedure planning, from 2017 to 2019. Baseline clinical and demographical data were collected. Patients with known history of coronary artery disease (CAD) and moderate to severe valvular heart disease were excluded. CACS was assessed using the Agatston method. Recurrence was defined as any documented episode of AF, atrial flutter or atrial tachycardia after 3 months from procedure. Patients were stratified in CACS&lt;100 and CACS≥100. Explorative analysis incorporated Kaplan-Meier survival curves and Cox regression.

Results

A total of 354 patients were included, with a mean age of 56 ± 12 years, 66% male and 21% with persistent AF. More than half of the patients had a CACS&gt;0 (n=185, 52%) and 63 patients (18%) had a CACS≥100. Patients with CACS≥100 were older (63 ± 7 vs 54 ± 12 years, p&lt;0.001), had higher prevalence of hypertension (68% vs 43%, p&lt;0.001) and diabetes mellitus (21% vs 10%, p=0.012) and higher left atrial volume (39 ± 9 vs 35 ± 9 ml/m2, p=0.018). After a median observation time of 34 months (IQR 24-43), 117 patients (33%) had AF recurrence.

CACS≥100 was associated with increased risk of AF recurrence (unadjusted Cox regression: hazard ratio [HR] 1.85; 95% confidence interval [CI], 1.23-2.79, p=0.003) (Fig. 1). After covariate adjustment (age, gender, hypertension, diabetes mellitus, obesity, thyroid disease, AF type and left atria enlargement) CACS≥100 remained an independent predictor of the risk of AF recurrence (HR, 1.68; 95% CI, 1.05-2.70, p=0.03) as well as persistent AF (HR, 1.91; 95% CI, 1.23-3.00, p=0.004) (Fig. 2).

Conclusion

In patients with AF undergoing catheter ablation, without previous history of CAD, a CACS≥100 was independently associated with a 68% increase in the risk of AF recurrence.

Association of epicardial adipose tissue and coronary artery calcium score in patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Both coronary artery calcium (CAC) and epicardial adipose tissue (EAT) had been implicated in coronary artery disease (CAD) and risk of future adverse cardiovascular events. There are scarce data regarding the assessment and association of EAT volume and CAC score (CACS) in atrial fibrillation (AF) patients.

Purpose

To assess the association between EAT volume and the presence and severity of CAC in patients with AF.

Methods

Retrospective and single-centre study including consecutive patients with AF undergoing contrast-enhanced cardiac computed tomography for catheter ablation planning, from 2017 to 2019. Patients with known history of CAD and moderate to severe valvular heart disease were excluded. Baseline clinical and demographical data were collected, as well as their cardiovascular risk, based on the SCORE (Systematic Coronary Risk Evaluation) system and cardiovascular risk categories. We assessed CACS (Agatston method) and EAT volume and analysed their association. EAT was defined as the adipose tissue accumulated between the visceral pericardium and the myocardium and was semi-automatically reconstructed by manually tracing the pericardium. Patients were split into three groups according to CACS: 0, 1-99 and ≥100. A logistic regression (LR) analysis was performed to explore the relationship between EAT volume and the presence of CAC (CACS&gt;0), adjusted for age, gender, obesity, diabetes mellitus and hypertension.

Results

A total of 354 patients were included, with a mean age of 56 ± 12 years, 66% male and 21% with persistent AF. A CHA2DS2-VASc score ≥2 was present in 130 (37%) patients and most patients had low to moderate cardiovascular risk (n=213, 82%). More than half of the patients had a CACS&gt;0 (n=185, 52%), of which 63 patients (18%) had a CACS≥100. The mean EAT volume was 79 ± 39 ml. There was a significant association between EAT volume and the presence of CAC: CACS=0 69 ± 34 ml vs CACS 1-99 84 ± 38 ml vs CACS ≥100 95 ± 45 ml (p&lt;0.001) (Fig. 1). After covariate adjustment (LR model R2 = 0.373, p &lt;0.0001), the presence of CAC was not associated with EAT volume (OR 1.00, 95%CI 1.00 - 1.01, p=0.2) or obesity, and only with higher age, male gender, hypertension and diabetes mellitus (Fig. 2).

Conclusion

In our cohort of patients with AF undergoing catheter ablation we observed an association between EAT and CACS. Nevertheless, EAT volume was not an independent predictor of CACS and only the classical cardiovascular risk factors remained significant.

Global plant trait relationships extend to the climatic extremes of the tundra biome

The majority of variation in six traits critical to the growth, survival and reproduction of plant species is thought to be organised along just two dimensions, corresponding to strategies of plant size and resource acquisition. However, it is unknown whether global plant trait relationships extend to climatic extremes, and if these interspecific relationships are confounded by trait variation within species. We test whether trait relationships extend to the cold extremes of life on Earth using the largest database of tundra plant traits yet compiled. We show that tundra plants demonstrate remarkably similar resource economic traits, but not size traits, compared to global distributions, and exhibit the same two dimensions of trait variation. Three quarters of trait variation occurs among species, mirroring global estimates of interspecific trait variation. Plant trait relationships are thus generalizable to the edge of global trait-space, informing prediction of plant community change in a warming world.

Prevention and management of unprofessional behaviour among adults in the workplace: A scoping review

BACKGROUND

Unprofessional behaviour is a challenge in academic medicine. Given that faculty are role models for trainees, it is critical to identify strategies to manage these behaviours. A scoping review was conducted to identify interventions to prevent and manage unprofessional behaviour in any workplace or professional setting.

METHODS

A search of 14 electronic databases was conducted in March 2016, reference lists of relevant systematic reviews were scanned, and grey literature was searched to identify relevant studies. Experimental and quasi-experimental studies that reported on interventions to prevent or manage unprofessional behaviours were included. Studies that reported impact on any outcome were eligible. Two reviewers independently screened articles and completed data abstraction. Qualitative analysis of the definitions of unprofessional behaviour was conducted. Data were charted to describe the study, participant, intervention and outcome characteristics.

RESULTS

12,482 citations were retrieved; 23 studies with 11,025 participants were included. The studies were 12 uncontrolled before and after studies, 6 controlled before and after studies, 2 cluster-randomised controlled trials (RCTs), 1 RCT, 1 non-randomised controlled trial and 1 quasi-RCT. Four constructs were identified in the definitions of unprofessional behaviour: verbal and/or non-verbal acts, repeated acts, power imbalance, and unwelcome behaviour. Interventions most commonly targeted individuals (22 studies, 95.7%) rather than organisations (4 studies, 17.4%). Most studies (21 studies, 91.3%) focused on increasing awareness. The most frequently targeted behaviour change was sexual harassment (4 of 7 studies).

DISCUSSION

Several interventions appear promising in addressing unprofessional behaviour. Most of the studies included single component, in-person education sessions targeting individuals and increasing awareness of unprofessional behaviour. Fewer studies targeted the institutional culture or addressed behaviour change.

Deposition of inhaled nanoparticles is reduced in subjects with COPD and correlates with the extent of emphysema: proof of concept for a novel diagnostic technique

BACKGROUND

The diagnosis of chronic obstructive pulmonary disease (COPD) is often based on spirometry, which is not sensitive to early emphysema. We have recently described a method for assessing distal airspace dimensions by measuring recovery of nanoparticles in exhaled air after a single-breath inhalation followed by breath-hold. Recovery refers to the non-deposited particle fraction. The aim of this study was to explore differences in the recovery of exhaled nanoparticles in subjects with COPD and never-smoking controls. A secondary aim was to determine whether recovery correlates with the extent of emphysema.

METHOD

A total of 19 patients with COPD and 19 controls underwent three repeats of single-breath nanoparticle inhalation followed by breath-hold. Particle concentrations in the inhaled aerosol, and in an alveolar sample exhaled after breath-hold, were measured to obtain recovery.

FINDINGS

The patients with COPD had a significantly higher mean recovery than controls, 0·128 ± 0·063 versus 0·074 ± 0·058; P = 0·010. Also, recovery correlated significantly with computed tomography (CT) densitometry variables (P<0·01) and diffusing capacity for carbon monoxide (DL,CO ; P = 0·002).

INTERPRETATION

Higher recovery for emphysema patients, relative to controls, is explained by larger diffusion distances in enlarged distal airspaces. The nanoparticle inhalation method shows potential to be developed towards a tool to diagnose emphysema.

Engaging policy-makers, health system managers, and policy analysts in the knowledge synthesis process: a scoping review

Background

It is unclear how to engage a wide range of knowledge users in research. We aimed to map the evidence on engaging knowledge users with an emphasis on policy-makers, health system managers, and policy analysts in the knowledge synthesis process through a scoping review.

Methods

We used the Joanna Briggs Institute guidance for scoping reviews. Nine electronic databases (e.g., MEDLINE), two grey literature sources (e.g., OpenSIGLE), and reference lists of relevant systematic reviews were searched from 1996 to August 2016. We included any type of study describing strategies, barriers and facilitators, or assessing the impact of engaging policy-makers, health system managers, and policy analysts in the knowledge synthesis process. Screening and data abstraction were conducted by two reviewers independently with a third reviewer resolving discrepancies. Frequency and thematic analyses were conducted.

Results

After screening 8395 titles and abstracts followed by 394 full-texts, 84 unique documents and 7 companion reports fulfilled our eligibility criteria. All 84 documents were published in the last 10 years, and half were prepared in North America. The most common type of knowledge synthesis with knowledge user engagement was a systematic review (36%). The knowledge synthesis most commonly addressed an issue at the level of national healthcare system (48%) and focused on health services delivery (17%) in high-income countries (86%).

Policy-makers were the most common (64%) knowledge users, followed by healthcare professionals (49%) and government agencies as well as patients and caregivers (34%). Knowledge users were engaged in conceptualization and design (49%), literature search and data collection (52%), data synthesis and interpretation (71%), and knowledge dissemination and application (44%). Knowledge users were most commonly engaged as key informants through meetings and workshops as well as surveys, focus groups, and interviews either in-person or by telephone and emails. Knowledge user content expertise/awareness was a common facilitator (18%), while lack of time or opportunity to participate was a common barrier (12%).

Conclusions

Knowledge users were most commonly engaged during the data synthesis and interpretation phases of the knowledge synthesis conduct. Researchers should document and evaluate knowledge user engagement in knowledge synthesis.

Registration details

Open Science Framework (https://osf.io/4dy53/).

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0717-x) contains supplementary material, which is available to authorized users.

Increased epicardial fat and plasma leptin in type 1 diabetes independently of obesity

BACKGROUND AND AIM

Visceral fat and related adipokines, such as leptin and adiponectin, have been recently suggested to play a role in type 1 diabetes. Nevertheless epicardial fat, the visceral fat of the heart, has been poorly explored in type 1 diabetes. In this study we sought to measure epicardial fat thickness, plasma leptin and adiponectin levels in type 1 diabetic subjects.

METHODS AND RESULTS

15 subjects with type 1 diabetes (age 52.8 ± 12, 10 females, 5 males, BMI 27.8 ± 5.2) and 15 non-diabetic controls underwent echocardiographic epicardial fat thickness measurement and blood tests for adipokines and Hemoglobin A1c (HbA1c). There were no differences in BMI, age, sex, blood pressure, inflammatory markers and adiponectin between subjects with diabetes and controls. Daily insulin requirement of subjects with type 1 diabetes was 0.54 ± 0.2 UI/kg and HbA1c was 7.6 ± 1.0 reflecting acceptable glycemic control. Patients with Type 1 diabetes showed significantly higher epicardial fat thickness (7.2 ± 2.1 vs 4.9 ± 2.5 mm p < 0.01) and plasma leptin levels (25.9 ± 19 vs 18 ± 12 ng/ml p < 0.01) than controls. Leptin resulted in the best independent correlate of epicardial fat thickness (R(2) = 0.48, p = 0.04, β = 2.45).

CONCLUSIONS

Our study provides two major findings of novelty: 1) subjects with type 1 diabetes have higher epicardial fat and serum leptin levels than non-diabetic subjects, 2) epicardial fat thickness and serum leptin levels are the best independent correlates of each other in patients with type 1 diabetes independently of BMI, HbA1c, daily insulin requirement. The mechanisms that link epicardial fat to leptin levels in type 1 diabetes remain to be elucidated.

Adult B-cell acute lymphoblastic leukemia with two unrelated abnormal cytogenetic clones

The presence of two different abnormal cell lines at diagnosis in hematologic malignancies is rare and raises the question of etiology and pathogenesis--two separate malignant lineages occurring together or a common stem cell malignancy? We present a 64-year-old woman who was evaluated for low platelet count and peripheral blasts. On the basis of the morphology, flow cytometry, and lack of myeloid-associated markers, a diagnosis of precursor B-cell acute lymphoblastic leukemia (B-ALL) was made. Cytogenetic analysis of the diagnostic bone marrow (BM) specimen revealed two unrelated abnormal clones--one had a dicentric (7;9)(p11;p11), resulting in the deletion of 7p and 9p, and the other had only trisomy 8. The dic(7;9) is a rare but recurrent abnormality in B-ALL, while trisomy 8 as a sole abnormality is most commonly associated with myeloid malignancies. After standard treatment for B-ALL, BM cytogenetic analysis showed disappearance of the dic(7;9) cell line but persistence of cells with trisomy 8. The presence of two unrelated clones suggestive of concomitant malignancies, possibly B-ALL with an underlying MDS, may have arisen by different mechanisms.

Performance evaluation of 70 hepatitis B virus (HBV) surface antigen (HBsAg) assays from around the world by a geographically diverse panel with an array of HBV genotypes and HBsAg subtypes

BACKGROUND AND OBJECTIVES

This study was conducted by the International Consortium for Blood Safety (ICBS) to identify high-quality test kits for detection of hepatitis B virus (HBV) surface antigen (HBsAg) for the benefit of developing countries.

MATERIALS AND METHODS

The 70 HBsAg test kits from around the world were evaluated comparatively for their clinical sensitivity, analytical sensitivity, sensitivity to HBV genotypes and HBsAg subtypes, and specificity using 394 (146 clinical, 48 analytical and 200 negative) ICBS Master Panel members of diverse geographical origin comprising the major HBV genotypes A-F and the HBsAg subtypes adw2,4, adr and ayw1-4.

RESULTS

Seventeen HBsAg enzyme immunoassay (EIA) kits had high analytical sensitivity <0.13 IU/ml, showed 100% diagnostic sensitivity, and were even sensitive for the various HBV variants tested. An additional six test kits had high sensitivity (<0.13 IU/ml) but missed HBsAg mutants and/or showed reduced sensitivity to certain HBV genotypes. Twenty HBsAg EIA kits were in the sensitivity range of 0.13-1 IU/ml. The other eight EIAs and the 19 rapid assays had analytical sensitivities of 1 to >4 IU/ml. These assays were falsely negative for 1-4 clinical samples and 17 of these test kits showed genotype dependent sensitivity reduction. Analytical sensitivities for HBsAg of >1 IU/ml significantly reduce the length of the HBsAg positive period which renders them less reliable for detecting HBsAg in asymptomatic HBV infections. Reduced sensitivity for HBsAg with genetic diversity of HBV occurred with genotypes/subtypes D/ayw3, E/ayw4, F/adw4 and by S gene mutants. Specificity of the HBsAg assays was >or=99.5% in 57 test kits and 96.4-99.0% in the remaining test kits.

CONCLUSION

Diagnostic efficacy of the evaluated HBsAg test kits differed substantially. Laboratories should therefore be aware of the analytical sensitivity for HBsAg and check for the relevant HBV variants circulating in the relevant population.

Performance evaluation of 70 hepatitis B virus (HBV) surface antigen (HBsAg) assays from around the world by a geographically diverse panel with an array of HBV genotypes and HBsAg subtypes

BACKGROUND AND OBJECTIVES

This study was conducted by the International Consortium for Blood Safety (ICBS) to identify high-quality test kits for detection of hepatitis B virus (HBV) surface antigen (HBsAg) for the benefit of developing countries.

MATERIALS AND METHODS

The 70 HBsAg test kits from around the world were evaluated comparatively for their clinical sensitivity, analytical sensitivity, sensitivity to HBV genotypes and HBsAg subtypes, and specificity using 394 (146 clinical, 48 analytical and 200 negative) ICBS Master Panel members of diverse geographical origin comprising the major HBV genotypes A-F and the HBsAg subtypes adw2,4, adr and ayw1-4.

RESULTS

Seventeen HBsAg enzyme immunoassay (EIA) kits had high analytical sensitivity <0.13 IU/ml, showed 100% diagnostic sensitivity, and were even sensitive for the various HBV variants tested. An additional six test kits had high sensitivity (<0.13 IU/ml) but missed HBsAg mutants and/or showed reduced sensitivity to certain HBV genotypes. Twenty HBsAg EIA kits were in the sensitivity range of 0.13-1 IU/ml. The other eight EIAs and the 19 rapid assays had analytical sensitivities of 1 to >4 IU/ml. These assays were falsely negative for 1-4 clinical samples and 17 of these test kits showed genotype dependent sensitivity reduction. Analytical sensitivities for HBsAg of >1 IU/ml significantly reduce the length of the HBsAg positive period which renders them less reliable for detecting HBsAg in asymptomatic HBV infections. Reduced sensitivity for HBsAg with genetic diversity of HBV occurred with genotypes/subtypes D/ayw3, E/ayw4, F/adw4 and by S gene mutants. Specificity of the HBsAg assays was >or=99.5% in 57 test kits and 96.4-99.0% in the remaining test kits.

CONCLUSION

Diagnostic efficacy of the evaluated HBsAg test kits differed substantially. Laboratories should therefore be aware of the analytical sensitivity for HBsAg and check for the relevant HBV variants circulating in the relevant population.

Analysis of lymphocyte and oral mucosa cell micronuclei in Cuban paint industry workers

Twenty-one workers exposed to complex mixtures in the paint industry were compared with a control group of 19 persons from a blood bank in regard to micronuclei frequency in peripheral blood lymphocytes and in oral mucosa cells. The exposed persons showed significantly increased levels of micronuclei frequencies in both types of cells.

Metabolic radiolabeling of animal cell glycoconjugates

This unit describes metabolic labeling techniques that provide specific information about the structure, sequence, and distribution of the sugar chains of glycoconjugates. In the Basic Protocol, cells in culture are grown through several population doublings in complete medium supplemented with radiolabeled glycoconjugate precursors to reach a steady-state level of incorporation. In the alternate protocols, cells are cultured for a short period of time in a deficient medium that contains a high concentration of radiolabeled precursor. A pulse or pulse-chase labeling procedure is provided to analyze precursor-product relationships. With the sequential pulse-labeling method described here, it is possible to obtain quantities of labeled glycoconjugates with the use of a minimum amount of labeled precursor by using the same batch of medium to pulse-label a series of cultures. A support protocol describes the preparation of multiply deficient medium (MDM) for use in making appropriate deficient media.

Development of the International Consortium for Blood Safety (ICBS) HCV panels

To evaluate the sensitivity and specificity of assays used to screen blood for antibody to hepatitis C virus (HCV) infection, the International Consortium for Blood Safety (ICBS) established fully characterized CBS panels. lCBS collected and characterized 1007 anti-HCV-positive plasma units from geographically diverse origins by ELISA, RIBA, RT-PCR, and sequence-based genotyping, 539 of which met the definition of a true positive. Of these, 200 confirmed positive plasma units, representing the 6 major HCV genotypes, were selected to assemble the true-positive constituents of the panel. The negative panel comprises 181 plasma units collected from the USA. The panels have proved valuable for determining the performance of anti-HCV assays thus permitting national authorities, especially in resource-limited countries, to make informed decisions on selection of affordable and reliable assays.

Metabolic radiolabeling of animal cell glycoconjugates

This unit describes metabolic labeling techniques that provide specific information about the structure, sequence, and distribution of the sugar chains of glycoconjugates. Although these techniques provide less information than complete sequencing of the sugar chains, the partial structural information derived is sufficient for many purposes. In the basic procedure presented in this unit, actively growing cell cultures are grown through several population doublings in complete medium supplemented with radiolabeled glycoconjugate precursors to reach a steady-state level of incorporation. In alternate protocols, cells are cultured for a short period of time in a deficient medium that contains a high concentration of radiolabeled precursor. A pulse or pulse-chase labeling procedure can be used to analyze precursor-product relationships. With sequential pulse-labeling, it is possible to obtain quantities of labeled glycoconjugates with the use of a minimal amount of labeled precursor by using the same medium to pulse-label a series of cultures. A support protocol describes the preparation of multiply deficient medium (MDM) for use in making appropriate deficient media.

Histologic results 1 year after bioprosthetic repair of paraesophageal hernia in a canine model

BACKGROUND

The use of prosthetic materials for the repair of paraesophageal hiatal hernia (PEH) may lead to esophageal stricture and perforation. High recurrence rates after primary repair have led surgeons to explore other options, including various bioprostheses. However, the long-term effects of these newer materials when placed at the esophageal hiatus are unknown. This study assessed the anatomic and histologic characteristics 1 year after PEH repair using a U-shaped configuration of commercially available small intestinal submucosa (SIS) mesh in a canine model.

METHODS

Six dogs underwent laparoscopic PEH repair with SIS mesh 4 weeks after thoracoscopic creation of PEH. When the six dogs were sacrificed 12 months later, endoscopy and barium x-ray were performed, and biopsies of the esophagus and crura were obtained.

RESULTS

The mean weight of the dogs 1 year after surgery was identical to their entry weight. No dog had gross dysphagia, evidence of esophageal stricture, or reherniation. At sacrifice, the biomaterial was not identifiable grossly. Biopsies of the hiatal region showed fibrosis as well as muscle fiber proliferation and regeneration. No dog had erosion of the mesh into the esophagus.

CONCLUSIONS

This reproducible canine model of PEH formation and repair did not result in erosion of SIS mesh into the esophagus or in stricture formation. Native muscle ingrowth was noted 1 year after placement of the biomaterial. According to the findings, SIS may provide a scaffold for ingrowth of crural muscle and a durable repair of PEH over the long term.

Access to emergency contraception

The introduction of emergency contraception (EC) has encountered barriers derived from the erroneous perception of EC as an abortificient and conservative attitudes. In several countries, "prolife" groups have initiated lawsuits against national regulatory bodies for approving EC. Other barriers are limited availability and high price of dedicated products, lack of information among providers about EC and the requirement of medical prescription for EC. The availability of EC has increased in the last years due to efforts of multiple stakeholders. Facilitating factors include the acceptability of EC by users and providers; dissemination of information about EC; advocacy among policymakers; training of providers; registration of dedicated products; over the counter sales and inclusion of EC in the national norms. By 2005, 109 countries have registered around 50 dedicated products that are available in public services, pharmacies, NGOs or through social marketing and 45 countries have included EC in their national norms.

Tobacco use in the Dominican Republic: understanding the culture first

OBJECTIVE

To conduct formative research on the landscape of tobacco use to guide survey and subsequent intervention development in the Dominican Republic (DR).

DESIGN

Rapid Assessment Procedures, systematic qualitative methods (participant-observations, in-depth interviewing, focus groups) using bilingual mixed age and gendered teams from the United States and DR.

SUBJECTS

Over 160 adults (men and women), ages 18 to 90 years, current, former and never smokers, community members and leaders from six underserved, economically disadvantaged DR communities.

MAIN OUTCOME MEASURES

Key domains: tobacco use patterns and attitudes; factors affecting smoking initiation, continuation, quitting; perceived risks/benefits/effects of smoking; and awareness/effects of advertising/regulations.

RESULTS

Perceptions of prevalence varied widely. While "everybody" smokes, smokers or ex-smokers were sometimes difficult to find. Knowledge of health risks was limited to the newly mandated statement "Fumar es prejudicial para la salud" [Smoking is harmful to your health]. Smokers started due to parents, peers, learned lifestyle, fashion or as something to do. Smoking served as an escape, relaxation or diversion. Quit attempts relied on personal will, primarily for religious or medical reasons. Social smoking (custom or habit) (< 10 cigarettes per day) was viewed as a lifestyle choice rather than a vice or addiction. Out of respect, smokers selected where they smoked and around whom. Health care providers typically were reactive relative to tobacco cessation, focusing on individuals with smoking related conditions. Tobacco advertising was virtually ubiquitous. Anti-tobacco messages were effectively absent. Cultures of smoking and not smoking coexisted absent a culture of quitting.

CONCLUSIONS

Systematic qualitative methods provided pertinent information about tobacco attitudes and use to guide subsequent project steps. Integrating qualitative then quantitative research can be replicated in similar countries that lack empirical data on the cultural dimensions of tobacco use.

Ozone and UV Radiation over Southern South America: Climatology and Anomalies

Ozone and UV radiation were analyzed at eight stations from tropical to sub-Antarctic regions in South America. Ground UV irradiances were measured by multichannel radiometers as part of the Inter American Institute for Global Change Radiation network. The irradiance channels used for this study were centered at 305 nm (for UV-B measurements) and 340 nm (for UV-A measurements). Results were presented as daily maximum irradiances, as monthly averaged, daily integrated irradiances and as the ratio of 305 nm to 340 nm. These findings are the first to be based on a long time series of semispectral data from the southern region of South America. As expected, the UV-B channel and total column ozone varied with latitude. The pattern of the UV-A channel was more complex because of local atmospheric conditions. Total column ozone levels of < 220 Dobson Units were observed at all sites. Analysis of autocorrelations showed a larger persistence of total column ozone level than irradiance. A decreasing cross-correlation coefficient between 305 and 340 nm and an increasing cross-correlation coefficient between 305 nm and ozone were observed at higher latitudes, indicating that factors such as cloud cover tend to dominate at northern sites and that ozone levels tend to dominate at southern sites. These results highlight the value of long-term monitoring of radiation with multichannel radiometers to determine climatological data and evaluate the combination of factors affecting ground UV radiation.

A novel cytogenetic abnormality in Burkitt lymphoma associated with treatment resistant disease

We present a patient with deletion of IgH associated with the reciprocal translocation (8;14) in Burkitt lymphoma. The patient had treatment resistant disease and died 10 weeks after diagnosis. The deletion was detected by fluorescence in situ hybridization at diagnosis and again after failure of chemotherapy. To our knowledge this is the first report of such a deletion.

Laparoscopic incisional hernia repair in a porcine model: what do transfixion sutures add?

BACKGROUND

The aim of this study was to evaluate the need for transfixion sutures during laparoscopic ventral hernia repair with mesh.

METHODS

Incisional hernias were created in 14 Yucatan mini-pigs. Animals were randomized to undergo laparoscopic hernia repair either with spiral tacks alone (Tacks) or with tacks and 4 Prolene transfixion sutures (Sutured) using Composix E/X mesh (Davol Inc.). At 4 weeks, exploratory laparoscopy was performed to assess the repair and score adhesions. The abdominal wall was harvested for tensile strength analysis and histologic evaluation. Continuous variables were compared using a two-tailed nonpaired t-test. Results are presented as mean +/- standard deviation.

RESULTS

The mean hernia size was 8.5 +/- 0.5 cm by 5.5 +/- 0.7 cm, with no difference between groups. The operative time was significantly longer ( p = 0.006) for the Sutured group (62.1 +/- 16.8 min) than for the Tacks group (32.3 +/- 7.0 min). The number of tacks per repair was equivalent between groups. At necropsy, the mesh in all cases was well incorporated, reperitonealized, and without evidence of migration. No hernias recurred. However, the Sutured group had a significantly ( p < or = 0.05) higher adhesion score (5.4 +/- 3.3) than the Tacks group (2.0 +/- 2.7). The tensile strength of the repair zone was no different between groups (Sutured 4.8 +/- 1.5 N/cm, Tacks 3.8 +/- 1.4 N/cm). On histologic examination, the ratio of inflammatory cells to fibroblasts was similar between groups (Sutured 0.2 +/- 0.6, Tacks 0.2 +/- 0.3). Only 82% of tacks in each group penetrated the fascia, and the depth of tack penetration was similar between groups (Sutured 3.7 +/- 0.3 mm, Tacks 3.9 +/- 0.4 mm).

CONCLUSIONS

In a porcine model, the use of transfixion sutures was associated with longer operative times and more adhesions, without improvement in tensile strength or mesh incorporation. A human clinical trial is needed to determine the optimal method of securing abdominal wall mesh.

Effects of formulation variables and post-compression curing on drug release from a new sustained-release matrix material: polyvinylacetate-povidone

A new commercially available sustained-release matrix material, Kollidon SR, composed of polyvinylacetate and povidone, was evaluated with respect to its ability to modulate the in vitro release of a highly water-soluble model compound, diphenhydramine HCl. Kollidon SR was found to provide a sustained-release effect for the model compound, with certain formulation and processing variables playing an important role in controlling its release kinetics. Formulation variables affecting the release include the level of the polymeric material in the matrix, excipient level, as well as the nature of the excipients (water soluble vs. water insoluble). Increasing the ratio of a water-insoluble excipient, Emcompress, to Kollidon SR enhanced drug release. The incorporation of a water-soluble excipient, lactose, accelerated its release rate in a more pronounced manner. Stability studies conducted at 40 degrees C/75% RH revealed a slow-down in dissolution rate for the drug-Kollidon SR formulation, as a result of polyvinylacetate relaxation. Further studies demonstrated that a post-compression curing step effectively stabilized the release pattern of formulations containing > or = 47% Kollidon SR. The release mechanism of Kollidon-drug and drug-Kollidon-Emcompress formulations appears to be diffusion controlled, while that of the drug-Kollidon-lactose formulation appears to be controlled predominantly by diffusion along with erosion.

Informed consent procedures: responsibilities of researchers in developing countries

We describe the informed consent procedures in a research clinic in Santiago, Chile, and a qualitative study that evaluated these procedures. The recruitment process involves information, counseling and screening of volunteers, and three or four visits to the clinic. The study explored the decision-making process of women participating in contraceptive trials through 36 interviews. Women understood the research as experimentation or progress. The decision to participate was facilitated by the information provided; time to consider it and to discuss it with partners or relatives; and perceived benefits such as quality of care, non-cost provision of methods and medical care. For some women, participation was an opportunity to express altruism. The main obstacles for participation were perceived side effects or risks. The final risk-benefit balance was strongly influenced by women's needs. Women perceived that the consent form benefited the clinic, proving that participants had made a free decision, and benefited the volunteers by warranting their right to free medical care. The most important problem detected was occasional misunderstanding of the information given on the form. We concluded that a full decision-making process enhances women's ability to exercise their right to choose, and assures research institutions that trials are conducted without coercion and that the participants are committed to the study. Researchers have the responsibility of conducting this process.

Echocardiographic evaluation of left-ventricular diastolic function in patients with chronic pulmonary hypertension

Different patterns of left-ventricular (LV) diastolic dysfunction were reported in patients with pulmonary hypertension (PHT). There are no data regarding the relationship between the severity of PHT and LV diastolic dysfunction. In order to determine the severity of PHT at which LV diastolic dysfunction occurs and to identify its pattern, we studied by Doppler echocardiography 120 patients with PHT (57 with severe PHT and 63 with mild or moderate PHT) and compared them with 75 normal controls. Systolic pulmonary artery pressure (SPAP) was measured by tricuspid regurgitant jet method and the usual transmitral LV diastolic indices were recorded. LV diastolic dysfunction of impaired relaxation type is most commonly seen in patients with severe PHT. No differences were observed between patients with mild and moderate PHT regarding LV diastolic function. A SPAP > or =60 mm Hg is needed to induce changes in the LV diastolic filling pattern.

Levonorgestrel concentrations during 7 years of continuous use of Jadelle contraceptive implants

Serum levonorgestrel concentrations were assayed in a multicenter, 7-year study of 199 users of Jadelle rod implants. We examined drug levels, patterns of changes, factors affecting drug levels, and concentrations at which pregnancies occurred. Mean levonorgestrel concentrations declined from 435 pg/mL at 1 month of use to 64% of that value (280 pg/mL) at the end of 3 years. Between the end of the third and fifth years neither mean nor median serum levels varied markedly. At 5 years the mean concentration was again 64% of the first month's mean. Declining levels were observed thereafter through the end of 7 years when the mean, 224 pg/mL, was 52% of the 1-month value. Last measured drug concentrations of women who became pregnant during Jadelle use had mean and median values of 152 and 144 pg/mL, respectively, and a maximum value of 180 pg/mL. Analyses indicated ponderal index, body weight, duration of use, and a single clinical center were the most important variables affecting measured levonorgestrel levels. Approximately one-third of assays in the sixth and seventh years were found to be below 180 pg/mL, suggesting that Jadelle levonorgestrel implants would not maintain sufficiently high levels of effectiveness against pregnancy after 5 years and that heavier women would then be at greater risk of pregnancy.

Proteomic comparison of human and great ape blood plasma reveals conserved glycosylation and differences in thyroid hormone metabolism

Most blood plasma proteins are glycosylated. These glycoproteins typically carry sialic acid-bearing sugar chains, which can modify the observed molecular weights and isoelectric points of those proteins during electrophoretic analyses. To explore changes in protein expression and glycosylation that occurred during great ape and human evolution, we subjected multiple blood plasma samples from all these species to high-resolution proteomic analysis. We found very few species-specific differences, indicating a remarkable degree of conservation of plasma protein expression and glycosylation during approximately 12 million years of evolution. A few lineage-specific differences in protein migration were noted among the great apes. The only obvious differences between humans and all great apes were an apparent decrease in transthyretin (prealbumin) and a change in haptoglobin isoforms (the latter was predictable from prior genetic studies). Quantitative studies of transthyretin in samples of blood plasma (synthesized primarily by the liver) and of cerebrospinal fluid (synthesized locally by the choroid plexus of the brain) confirmed approximately 2-fold higher levels in chimpanzees compared to humans. Since transthyretin binds thyroid hormones, we next compared plasma thyroid hormone parameters between humans and chimpanzees. The results indicate significant differences in the status of thyroid hormone metabolism, which represent the first known endocrine difference between these species. Notably, thyroid hormones are known to play major roles in the development, differentiation, and metabolism of many organs and tissues, including the brain and the cranium. Also, transthyretin is known to be the major carrier of thyroid hormone in the cerebrospinal fluid, likely regulating delivery of this hormone to the brain. A potential secondary difference in retinoid (vitamin A) metabolism is also noted. The implications of these findings for explaining unique features of human evolution are discussed.

Incidence of and risk factors for medical complications during stroke rehabilitation

BACKGROUND AND PURPOSE

The aims of this study were to examine the frequency, types, and clinical factors associated with medical complications that occur during inpatient rehabilitation and to identify risk factors for complications that require a transfer to an acute care facility.

METHODS

A cohort of 1029 patients consecutively admitted for inpatient stroke rehabilitation was studied. Demographic and stroke information, impairment, preexisting medical conditions, and admission laboratory abnormalities were recorded. Medical complications, defined as new or exacerbated medical problems, were documented for each patient. Complications that required transfer off rehabilitation were noted. Univariate and multiple logistic regression analyses were used to determine factors that were associated with risk of medical complications and risk of transfer off rehabilitation.

RESULTS

Seventy-five percent of patients experienced >/=1 medical complication during rehabilitation. Significant factors for the development of any medical complication included greater neurological deficit (odds ratio [OR], 4.10; confidence interval [CI], 1.88 to 8.91), hypoalbuminemia (OR, 1.71; 95% CI, 1.15 to 2.52), and history of hypertension (OR, 1.81; 95% CI, 1.27 to 2.59). Nineteen percent of patients had a medical complication that required transfer to an acute care facility. Significant factors for transfers were elevated admission white blood cell counts (OR, 1.92; 95% CI, 1.32 to 2.79), low admission hemoglobin levels (OR, 1.89; 95% CI, 1.32 to 2.68), greater neurological deficit (OR, 2.46; 95% CI, 1.37 to 4.39), and a history of cardiac arrhythmia (OR, 1.79; 95% CI, 1.18 to 2.67).

CONCLUSIONS

Medical complications are common among patients undergoing stroke rehabilitation. A significant number of these medical complications may require a transfer to an acute facility.

Behavioral interventions reduce infant distress at immunization

OBJECTIVE

To assess the effectiveness of simple behavioral interventions at immunization on behavioral and biochemical indicators of distress in infants and parents in a primary care setting.

DESIGN

Subjects were enrolled sequentially to control (standard care) and intervention groups. Intervention parents (n=57) were provided information about techniques to help their infants at immunization. Standard care parents (n=45) did not receive this information. Immunizations were videotaped and coded for infant and parent behaviors. Using a visual analog scale, parents rated their infant's and their own comfort at study enrollment, immediately after immunization, and at check-out. Saliva samples collected from infants and parents at study enrollment and at 15, 30, and 60 minutes after immunization were assayed for cortisol concentration by standard radioimmunoassay. Data were analyzed using chi2, analysis of variance, and general linear modeling. Patterns of salivary cortisol change after immunization were analyzed using hierarchical linear modeling.

SETTING

A single, urban pediatric practice during 2 summers (1997 and 1998).

SUBJECTS

Infants 2 to 24 months of age (n= 102) and their parents.

MAIN OUTCOME MEASURES

Duration of infant distress (in seconds); parent use of behavioral intervention; infant and parent salivary cortisol concentrations (in nanomoles per liter).

RESULTS

Intervention parents were more likely to use a behavioral technique with their infants before immunization (P<.05). Total infant distress was shorter for intervention infants at immunization (P<.01), and these infants were rated as more comfortable by their parents (P<.001) immediately after immunization. Salivary cortisol levels were lower for intervention infants at 15, 30, and 60 minutes after immunization (P<.05).

CONCLUSION

Simple behavioral interventions before immunization are associated with reductions in behavioral and biochemical indicators of infant distress.

Prolonged effectiveness of Norplant(R) capsule implants: a 7-year study

Soft tubing Norplant(R) contraceptive implants were studied in 1210 women for 7 years to measure the duration of effectiveness and the magnitude of the pregnancy rates over that time. Mean age at enrollment was 27.4 years. Of the enrollees, 42% were US residents. One-sixth (16.1%) weighed >/=70 kg at the time of implant placement. At the end of 5 years, the cumulative pregnancy rate was 1.1/100; at the end of 7 years, it was 1.9/100. No pregnancies occurred to any of the 400 women who enrolled in the study at age >/=30 years and who weighed <100 kg. Among women aged 18-33 years, the 7-year Norplant pregnancy rates are comparable to the median pregnancy rates of tubal sterilization methods for women of the same age and duration of use. For women aged >/=34 years, without regard to weight at admission, the 7-year effectiveness of soft tubing Norplant equals or surpasses that of tubal sterilization. For continuing implant users, annual pregnancy rates <1.0/100 in years 6 and 7, together with low cumulative pregnancy rates, testify that Norplant capsule implants remain highly effective for 7 years.