Adapting Behavioral Treatments for Primary Care Using a Theory-Based Framework: The Case of Adolescent Eating Disorders

Evidence-based treatments have been developed for a range of pediatric mental health conditions. These interventions have proven efficacy but require trained pediatric behavioral health specialists for their administration. Unfortunately, the widespread shortage of behavioral health specialists leaves few referral options for primary care providers. As a result, primary care providers are frequently required to support young patients during their lengthy and often fruitless search for specialty treatment. One solution to this treatment-access gap is to draw from the example of integrated behavioral health and adapt brief evidence-based treatments for intra-disciplinary delivery by primary care providers in consultation with mental health providers. This solution has potential to expand access to evidence-based interventions and improve patient outcomes. We outline how an 8-step theory-based process for adapting evidence-based interventions, developed from a scoping review of the wide range of implementation science frameworks, can guide treatment development and implementation for pediatric behavioral health care delivery in the primary care setting, using an example of our innovative treatment adaptation for child and adolescent eating disorders. After reviewing the literature, obtaining input from leaders in eating disorder treatment research, and engaging community stakeholders, we adapted Family-Based Treatment for delivery in primary care. Pilot data suggest that the intervention is feasible to implement in primary care and preliminary findings suggest a large effect on adolescent weight gain. Our experience using this implementation framework provides a model for primary care providers looking to develop intra-disciplinary solutions for other areas where specialty services are insufficient to meet patient needs.

The integration of palliative care with oncology: the path ahead

The delivery of comprehensive cancer care within a progressively intricate healthcare environment requires oncology providers to become well-versed in the integration of palliative care (PC). Moreover, as healthcare professionals are urged to prioritize the individual preferences of patients and their families who confront life-limiting illnesses, it has become evident that oncology patients and their families have identified their psychosocial care needs as multifaceted and distinct, calling for specialized attention from care providers. Nevertheless, this is a skill that can be acquired through learning and practice. The landscape of PC is rapidly changing, with paradigm shifting studies highlighting the importance of early concurrent palliative and oncology inpatient and outpatient care for those with new advanced cancer diagnosis. Early concurrent care can notably improve quality of life (QoL), symptom control, patient and caregiver satisfaction, reduce costs and even improve survival. There is no longer a question of if PC should be offered, but instead when referral should be completed, what is the optimal model for service delivery and what barriers are present to achieve concurrent care. Conceptual models have been identified for optimal integrated palliative and oncology care delivery. In order to provide the best integrated care however, multiple obstacles need to be overcome. This narrative review discusses the importance of early integrated oncology and PC for patients with advanced cancer diagnosis, as well as the barriers to the integration of these specialties and potential models for delivery.

Implementation of a Virtual Interprofessional ICU Learning Collaborative: Successes, Challenges, and Initial Reactions From the Structured Team-Based Optimal Patient-Centered Care for Virus COVID-19 Collaborators

Initial Society of Critical Care Medicine Discovery Viral Infection and Respiratory illness Universal Study (VIRUS) Registry analysis suggested that improvements in critical care processes offered the greatest modifiable opportunity to improve critically ill COVID-19 patient outcomes.

OBJECTIVES

The Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 ICU Collaborative was created to identify and speed implementation of best evidence based COVID-19 practices.

DESIGN SETTING AND PARTICIPANTS

This 6-month project included volunteer interprofessional teams from VIRUS Registry sites, who received online training on the Checklist for Early Recognition and Treatment of Acute Illness and iNjury approach, a structured and systematic method for delivering evidence based critical care. Collaborators participated in weekly 1-hour videoconference sessions on high impact topics, monthly quality improvement (QI) coaching sessions, and received extensive additional resources for asynchronous learning.

MAIN OUTCOMES AND MEASURES

Outcomes included learner engagement, satisfaction, and number of QI projects initiated by participating teams.

RESULTS

Eleven of 13 initial sites participated in the Collaborative from March 2, 2021, to September 29, 2021. A total of 67 learners participated in the Collaborative, including 23 nurses, 22 physicians, 10 pharmacists, nine respiratory therapists, and three nonclinicians. Site attendance among the 11 sites in the 25 videoconference sessions ranged between 82% and 100%, with three sites providing at least one team member for 100% of sessions. The majority reported that topics matched their scope of practice (69%) and would highly recommend the program to colleagues (77%). A total of nine QI projects were initiated across three clinical domains and focused on improving adherence to established critical care practice bundles, reducing nosocomial complications, and strengthening patient- and family-centered care in the ICU. Major factors impacting successful Collaborative engagement included an engaged interprofessional team; an established culture of engagement; opportunities to benchmark performance and accelerate institutional innovation, networking, and acclaim; and ready access to data that could be leveraged for QI purposes.

CONCLUSIONS AND RELEVANCE

Use of a virtual platform to establish a learning collaborative to accelerate the identification, dissemination, and implementation of critical care best practices for COVID-19 is feasible. Our experience offers important lessons for future collaborative efforts focused on improving ICU processes of care.

Facilitators and barriers to the implementation of new critical care practices during COVID-19: a multicenter qualitative study using the Consolidated Framework for Implementation Research (CFIR)

BACKGROUND

The COVID-19 pandemic produced unprecedented demands and rapidly changing evidence and practices within critical care settings. The purpose of this study was to identify factors and strategies that hindered and facilitated effective implementation of new critical care practices and policies in response to the pandemic.

METHODS

We used a cross-sectional, qualitative study design to conduct semi-structured in-depth interviews with critical care leaders across the United States. The interviews were audio-taped and professionally transcribed verbatim. Guided by the Consolidated Framework for Implementation Research (CFIR), three qualitative researchers used rapid analysis methods to develop relevant codes and identify salient themes.

RESULTS

Among the 17 hospitals that agreed to participate in this study, 31 clinical leaders were interviewed. The CFIR-driven rapid analysis of the interview transcripts generated 12 major themes, which included six implementation facilitators (i.e., factors that promoted the implementation of new critical care practices) and six implementation barriers (i.e., factors that hindered the implementation of new critical care practices). These themes spanned the five CFIR domains (Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals, and Process) and 11 distinct CFIR constructs. Salient facilitators to implementation efforts included staff resilience, commitment, and innovation, which were supported through collaborative feedback and decision-making mechanisms between leadership and frontline staff. Major identified barriers included lack of access to reliable and transferable information, available resources, uncollaborative leadership and communication styles.

CONCLUSIONS

Through applying the CFIR to organize and synthesize our qualitative data, this study revealed important insights into implementation determinants that influenced the uptake of new critical care practices during COVID-19. As the pandemic continues to burden critical care units, clinical leaders should consider emulating the effective change management strategies identified. The cultivation of streamlined, engaging, and collaborative leadership and communication mechanisms not only supported implementation of new care practices across sites, but it also helped reduce salient implementation barriers, particularly resource and staffing shortages. Future critical care implementation studies should seek to capitalize on identified facilitators and reduce barriers.

Time to diagnostic certainty for saddle pulmonary embolism in hospitalized patients

There is a lack of diagnostic performance measures associated with pulmonary embolism (PE). We aimed to explore the concept of the time to diagnostic certainty, which we defined as the time interval that elapses between first presentation of a patient to a confirmed PE diagnosis with computed tomography pulmonary angiogram (CT PA). This approach could be used to highlight variability in health system diagnostic performance, and to select patient outliers for structured chart review in order to identify underlying contributors to diagnostic error or delay. We performed a retrospective observational study at academic medical centers and associated community-based hospitals in one health system, examining randomly selected adult patients admitted to study sites with a diagnosis of acute saddle PE. One hundred patients were randomly selected from 340 patients discharged with saddle PE. Twenty-four patients were excluded. Among the 76 included patients, time to diagnostic certainty ranged from 1.5 to 310 hours. We found that 73/76 patients were considered to have PE present on admission (CT PA ≤ 48 hours). The proportion of patients with PE present on admission with time to diagnostic certainty of > 6 hours was 26% (19/73). The median (IQR) time to treatment (thrombolytics/anticoagulants) was 3.5 (2.5-5.1) hours among the 73 patients. The proportion of patients with PE present on admission with treatment delays of > 6 hours was 16% (12/73). Three patients acquired PE during hospitalization (CT PA > 48 hours). In this study, we developed and successfully tested the concept of time to diagnostic certainty for saddle PE.

Time to diagnostic certainty for saddle pulmonary embolism in hospitalized patients

There is a lack of diagnostic performance measures associated with pulmonary embolism (PE). We aimed to explore the concept of the time to diagnostic certainty, which we defined as the time interval that elapses between first presentation of a patient to a confirmed PE diagnosis with computed tomography pulmonary angiogram (CT PA). This approach could be used to highlight variability in health system diagnostic performance, and to select patient outliers for structured chart review in order to identify underlying contributors to diagnostic error or delay. We performed a retrospective observational study at academic medical centers and associated community-based hospitals in one health system, examining randomly selected adult patients admitted to study sites with a diagnosis of acute saddle PE. One hundred patients were randomly selected from 340 patients discharged with saddle PE. Twenty-four patients were excluded. Among the 76 included patients, time to diagnostic certainty ranged from 1.5 to 310 hours. We found that 73/76 patients were considered to have PE present on admission (CT PA ≤ 48 hours). The proportion of patients with PE present on admission with time to diagnostic certainty of > 6 hours was 26% (19/73). The median (IQR) time to treatment (thrombolytics/anticoagulants) was 3.5 (2.5-5.1) hours among the 73 patients. The proportion of patients with PE present on admission with treatment delays of > 6 hours was 16% (12/73). Three patients acquired PE during hospitalization (CT PA > 48 hours). In this study, we developed and successfully tested the concept of time to diagnostic certainty for saddle PE.

1911. A Pilot Study to Evaluate the Effectiveness of Nasal and Oral Povidone Iodine in Reducing the Burden of Severe Acute Respiratory Syndrome 2 RNA in Patients with COVID-19

Background

Nasal and oral application of topical antiseptics such as povidone iodine could potentially reduce the risk for transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, limited information is available on the efficacy of such agents in reducing the burden of SARS-CoV-2.

Methods

We conducted a pilot non-blinded, randomized trial to compare the effectiveness of 3 doses of povidone iodine (each dose with 10% intranasal and 1% gargle) administered every 8 hours versus the control with phosphate-buffered saline in reducing the burden of SARS-CoV-2 RNA in the nares and oropharynx of patients with COVID-19. Swabs were used to collect anterior nares and oropharynx samples before the first and second doses and 8 hours after the final dose (24 hours after the initial dose). Real-time polymerase-chain reaction (RT-PCR) was used to assess the burden of viral RNA. Analysis of variance was used to compare cycle threshold values for povidone iodine versus control patients. Subjects were surveyed about adverse reactions to treatment.

Results

As shown in the figure, SARS-CoV-2 cycle thresholds were similar in the povidone iodine (N=10 subjects) and control (N=8 subjects) groups prior to treatment. After initiation of treatment, there was no significant difference in cycle thresholds for the povidone iodine versus control subjects (P >0.05). No adverse effects of treatment were reported.

Effect of intranasal and oral application of povidone iodine versus phosphate-buffered saline on nasal and oropharyngeal SARS-CoV-2 RNA. Error bars show standard error.

Conclusion

Our findings suggest that that nasal and oral application of povidone iodine have limited effectiveness in reducing the burden of SARS-CoV-2. Future studies are needed to assess for effectiveness of more frequent dosing intervals and to determine if povidone iodine reduces recovery of viable virus by culture.

Disclosures

All Authors: No reported disclosures.

Contributors to Diagnostic Error or Delay in the Acute Care Setting: A Survey of Clinical Stakeholders

Diagnostic error or delay (DEOD) is common in the acute care setting and results in poor patient outcomes. Many factors contribute to DEOD, but little is known about how contributors may differ across acute care areas and professional roles. As part of a sequential exploratory mixed methods research study, we surveyed acute care clinical stakeholders about the frequency with which different factors contribute to DEOD. Survey respondents could also propose solutions in open text fields. N = 220 clinical stakeholders completed the survey. Care Team Interactions, Systems and Process, Patient, Provider, and Cognitive factors were perceived to contribute to DEOD with similar frequency. Organization and Infrastructure factors were perceived to contribute to DEOD significantly less often. Responses did not vary across acute care setting. Physicians perceived Cognitive factors to contribute to DEOD more frequently compared to those in other roles. Commonly proposed solutions included: technological solutions, organization level fixes, ensuring staff know and are encouraged to work to the full scope of their role, and cultivating a culture of collaboration and respect. Multiple factors contribute to DEOD with similar frequency across acute care areas, suggesting the need for a multi-pronged approach that can be applied across acute care areas.

A randomised control trial of TeleClinical Care – a smartphone-app based model of care for heart failure and acute coronary syndromes

Background

Acute coronary syndrome (ACS) and heart failure (HF) are frequent causes of hospitalisation and readmissions. A novel smartphone app-based model of care (TeleClinical Care – TCC) was developed to support patients after ACS or HF admission.

Purpose

This randomised control trial aimed to characterise both the intervention and clinical outcomes. The primary endpoint was the incidence of 30-day readmissions. Secondary endpoints included six-month cardiac and all-cause readmissions, mortality, major adverse cardiovascular events (MACE), cardiac rehabilitation (CR) completion, medication adherence, serum low-density lipoprotein (LDL-C), quality of life, blood pressure, body mass index, waist circumference and six-minute walk distance. Additionally, cost-effectiveness and user satisfaction were evaluated.

Methods

Patients were randomised 1:1 to either TCC plus usual care or usual care alone and were followed-up at six months. Intervention arm participants received the TCC app and were asked to use Bluetooth-enabled devices for measuring weight, heart rate, blood pressure and physical activity daily. Readings were automatically transmitted to the patient's smartphone and a secure web-server (KIOLA). Customisable thresholds for each parameter were defined at discharge. Abnormal readings were flagged by email to a monitoring team, who discussed management with the patient's usual healthcare providers. The app also provided educational push notifications.

Results

164 patients from two hospitals in Sydney, Australia were enrolled between February 2019 and March 2020 (TCC n=81, control n=83). Recruitment ceased during the COVID-19 pandemic. The mean age was 61.5 years. 79% of patients were male. The per-patient mean percentage of days with data transmission was 64.2±27.5%. 565 alerts were received, 16% of which resulted in additional investigations, healthcare consultation or a change in management. There was no difference in 30-day readmission rate (11 readmissions in each arm). There was a significant difference in six-month readmissions, favouring the intervention (21 vs. 41 readmissions, HR=0.40, 95% CI 0.16–0.95, P=0.03), driven by a reduction in cardiac readmissions (11 vs. 25, HR=0.51, 95% CI 0.27–0.94, P=0.03). Use of TCC was associated with improved CR completion (39% vs. 18%, P=0.025) and medication adherence (75% vs. 50%, P=0.002). There was no significant difference in mortality, MACE, LDL-C, quality of life or any of the physical parameters. The average user rating was 4.56 out of 5. The study cost EUR 4015 per readmission saved. Upon modelling, it was calculated that if the number of enrolled patients exceeds 243, total expenditure will be overcome by cost savings from reducing readmissions.

Conclusion

The TCC model of care was feasible and safe. In this study, clinical benefits were demonstrated including a reduction in six-month readmissions, improved CR completion and improved medication adherence.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Department of Cardiology, Prince of Wales HospitalPrince of Wales Hospital Foundation Figure 1. TCC interfaceFigure 2. Cumulative readmissions over the course of the trial

Connecting community-delivered evidence-based programs and the healthcare system: Piloting a learning "wellcare" system

INTRODUCTION

Many evidence-based programs (EBPs) have been determined in randomized controlled trials to be effective, but few studies explore the real-world effectiveness of EBPs implemented in the natural community setting. Our study evaluated whether a novel linked infrastructure would enable such insights and continuous improvement as part of a learning healthcare-community bridged "wellcare" ecosystem.

METHODS

We created a secure, web-based data entry and storage platform with a network of Minnesota community-based organizations to record EBP participants' demographics and attendance, and program details. We then linked participant's information to their Rochester Epidemiology Project (REP) medical records. With this infrastructure, we conducted a proof of concept, retrospective cohort study by matching EBP participants to REP controls and comparing medical record-documented outcomes over 1 year follow-up.

RESULTS

We successfully linked EBP participant records with medical records in 77.6% of cases, and the infrastructure proved feasible and scalable. Still, key challenges remain in obtaining participant consent for data sharing. Upfront resource investments and the availability of REP-like warehouses limit generalizability. Optimal learning will be improved by enhancements that better track program fidelity. Our pilot study established a proof-of-concept, but sample sizes (n = 99 for falls prevention and n = 97 chronic disease/pain management EBP completers) were too small to detect significant differences in hospital admittance as compared to matched controls for either EBP group, (OR = 0.66[0.36, 1.19]) and (OR = 0.81[0.43, 1.54]), respectively. Events were too rare to gather meaningful information about effects on fall rates.

CONCLUSIONS

Our pilot demonstrates the feasibility of developing an online infrastructure that connects information from community leaders with medical record documented health outcomes, bridging the knowledge gap between community programs and the health care system. Insights gleaned from our infrastructure can be used to continuously shape community program delivery to reduce the need for formal health care services.

Human subjects research as part of immunology education

Original research has been identified as a high impact practice in undergraduate education – students who participate have been shown to be more likely to be be successful in professional and academic graduate programs. Course-embedded research allows for students to tie laboratory experiences to classroom concepts and allows for many students to benefit from faculty oversight. Undergraduate research in immunology presents challenges because most models of immunology are limited to vertebrate organisms, which require additional regulatory oversight from Institutional Animal Care and Use Committees or Institutional Review Boards. One common solution is to limit student interaction with organisms by using isolated or cultured cells, however this prevents students from gaining a realistic understanding of all the stages of immunological research. Obtaining authorization for student-designed research, conducting the projects, and analyzing and presenting the results within a single semester is a daunting proposal, one which has been further complicated by the full implementation of the new Common Rule for human subjects research. We have developed a model for conducting human subjects research within a single semester of a junior-level undergraduate immunology course. By using a framework protocol, non-invasive sampling, and anonymized presented data we are able to work within IRB/IACUC regulations beyond the classroom exercise level, allowing students to share their findings with the broader campus community, in online portfolios, and at professional conferences. This model has been sustainable for five years at a public primarily undergraduate institution and has been successful under the new common rule regulations.

1218. Evaluation of a Novel Sporicidal Spray Disinfectant for Decontamination of Surfaces in Healthcare

Background

Surfaces in healthcare facilities are typically cleaned by manual application of liquid disinfectants. However, thoroughness of cleaning is often suboptimal and application can be challenging and time-consuming when surfaces are irregular.

Methods

We tested the effectiveness of a novel spray disinfectant technology that uses an electrostatic sprayer to thoroughly apply a sporicidal disinfectant to surfaces after minimal pre-cleaning to remove visible soil. In a laboratory setting, we compared the effectiveness of the spray disinfectant vs. manual application of disinfectant for removal of Clostridium difficile spores inoculated onto the seat, armrest, and seat back of a wheelchair and measured the time required for each method of disinfection. In a healthcare setting, we tested the effectiveness of a 15-second spray application for reduction of C. difficile spores on 130 items with irregular or hard to clean surfaces, including 30 wheelchairs, 40 pieces of portable equipment, and 30 waiting room chair seats.

Results

In laboratory testing, application of disinfectant using the electrostatic sprayer was as effective as wiping in reducing C. difficile spores inoculated onto wheelchair surfaces, but required only one-fourth the time for application. C. difficile spore contamination was common on mobile equipment, wheelchairs, and waiting rooms chairs, and spray application of the sporicidal disinfectant was effective in reducing contamination (figure).

Conclusion

Commonly shared items such as wheelchairs, portable equipment, and waiting room chairs were frequently contaminated with C. difficile spores. Application of a sporicidal disinfectant using an electrostatic sprayer provided a rapid and effective means to reduce spore contamination on these surfaces.

Disclosures

All authors: No reported disclosures.

1215. Ultraviolet-C (UV-C) Monitoring Made Ridiculously Simple: UV-C Dose Indicators for Convenient Measurement of UV-C Dosing

Background

Ultraviolet-C (UV-C) light is increasingly used as an adjunct to standard cleaning in healthcare facilities. However, most facilities do not have a means to measure UV-C to determine whether effective doses are being delivered. We tested the efficacy of 2 easy-to-use colorimetric indicators for monitoring UV-C dosing in comparison to log reductions in pathogens.

Methods

In a laboratory setting, we exposed methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile spores on steel disk carriers with or without an organic load (5% fetal calf serum) to UV-C for varying times resulting in fluence exposures ranging from 10,000 to 100,000 µJ/cm². The UV-C indicators were placed adjacent to the carriers. Log reductions were calculated in comparison to untreated controls and the change in color of the indicators was correlated with dose and log reductions.

Results

The UV-C doses required to achieve a 3-log reduction in MRSA and C. difficile were 10,000 and 46,000 µJ/cm², respectively. For both indicators, there was a visible color change from baseline at 10,000 µJ/cm² and a definite final color change by 46,000 µJ/cm² (Figure 1). Organic load had only a modest impact on UV-C efficacy. The indicators required only a few seconds to place and were easy to read (Figure 2).

Conclusion

UV-C doses of 10,000 and 46,000 µJ/cm² were required to achieve 3 log reductions of MRSA and C. difficile spores, respectively. The colorimetric indicators provide an easy means to monitor UV-C dosing.

Disclosures

All authors: No reported disclosures.

TNF Induces Pathogenic Programmed Macrophage Necrosis in Tuberculosis through a Mitochondrial-Lysosomal-Endoplasmic Reticulum Circuit

Necrosis of infected macrophages constitutes a critical pathogenetic event in tuberculosis by releasing mycobacteria into the growth-permissive extracellular environment. In zebrafish infected with Mycobacterium marinum or Mycobacterium tuberculosis, excess tumor necrosis factor triggers programmed necrosis of infected macrophages through the production of mitochondrial reactive oxygen species (ROS) and the participation of cyclophilin D, a component of the mitochondrial permeability transition pore. Here, we show that this necrosis pathway is not mitochondrion-intrinsic but results from an inter-organellar circuit initiating and culminating in the mitochondrion. Mitochondrial ROS induce production of lysosomal ceramide that ultimately activates the cytosolic protein BAX. BAX promotes calcium flow from the endoplasmic reticulum into the mitochondrion through ryanodine receptors, and the resultant mitochondrial calcium overload triggers cyclophilin-D-mediated necrosis. We identify ryanodine receptors and plasma membrane L-type calcium channels as druggable targets to intercept mitochondrial calcium overload and necrosis of mycobacterium-infected zebrafish and human macrophages.

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TNF induces mitochondrial ROS to cause necrosis of mycobacterium-infected macrophages

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Mitochondrial ROS activate lysosomal enzymes that lead to BAX activation

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BAX activates ER ryanodine receptors to cause Ca²⁺ flow into the mitochondrion

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Drugs preventing mitochondrial Ca²⁺ overload prevent pathogenic macrophage necrosis in TB

A speaking-intensive model for case studies in undergraduate immunology

Effective communication is consistently identified as a key attribute of successful graduates seeking employment or additional training. While most undergraduate programs place a focus on written communication, many interactions students have leading up to and during these new experiences require dialogue with peers, overseers, or the public. To prepare students for those interactions we use a group-presentation model in which students are responsible for three 50-minute presentations in their undergraduate immunology course. Student-led class sessions present challenges – real-time assessment, reliance on students to accurately and thoroughly convey information, and class engagement throughout the presentation. We use case studies as the basis for each presentation, with a set structure that requires presenters to address background, clinical details, scientific literature, and case-specific questions. Basic information is given to non-presenters and presenters receive additional information allowing for a preparatory meeting. Using a hybrid model for discussions, non-presenters can attempt to “solve” the case and ask questions before the class meets. In addition to the in-class assessment, students are graded on their preparation for the preparatory meeting and reflect on each other’s performance. Students were sampled at the beginning and end of the course using the CURE assessment (5 point scale), and reported a 0.74 point increase in critical thinking skills and a 0.44 point increase in speaking skills, as compared to a 0.09 point increase in other academic skills. We will share instructor, teaching assistant, and student perspectives.

Comparative analysis of stress on faculty and students based on salivary IgA

The goal of this project is to test students and faculties stress levels in their saliva compared between the beginning of this semester and the end of the semester. IgA levels are influenced by many physiological factors, including the hormones associated with stress. The findings conclude that there is significance between IgA levels in a student or faculty based on hours since they had left class and hours until they have class. Students and faculty showed a correlation between IgA and time since being in class or work (p-value = 0.03), however no significance of the duration of the expected rest period (p-value = 0.71). The significance of this finding is that students and faculty tend to be more stressed after being in class/work based on IgA levels in their saliva.

IgA You Assay? The Correlation between Sleep and Stress

The most well known fact about sleep is that humans need it - while we are asleep our metabolic processes slow down and during long periods of sleep our bodies repair the damage that the stress our bodies have undergone throughout the day. Throughout the day our bodies are bombarded by signals from the environment, and undergoes biological changes in response to external and internal stimuli. Sleep is a period of time to restore the body to optimum condition to continue the process all over again the next day. The human body regulates stress by producing glucocorticoid steroid hormones, which also function as immune response suppressants. During sleep cortisol levels are decreased as they inhibit the body’s period of restoration. The production of immunoglobulin A, an antibody associated with mucosal membranes, is inhibited by glucocorticoids, and thus shows a relationship with sleep and other factors associated with stress. This experiment focused on correlations between sleep and stress found on the campus of Radford University. Our groups recorded the amount of sleep participants acquired the previous night and how long they had been awake, and correlated these with the concentration of salivary IgA. According to our initial data collection there was no significant correlation between the amount of sleep (p=0.305) or hours awake (0.670) to IgA levels. Additional sampling later in the semester will be used to supplement this data set and mapped using geospatial coordinates.

Our Own Worst Enemy: Psychosomatic effects of perceived stress on IgA levels

Our study is to determine and compare human IgA levels to self reported stress levels of college students and faculty at the beginning of the college semester, when stress levels are expected to be low, as compared to a later point in the semester, when stress levels are expected to be higher. This study is significant because the data will provide us with information regarding whether or not people are as biologically stressed as they report at different periods of the semester. Individuals are expected to be at a lower stress level at the beginning of the semester than at the end of the semester. Biological stressors are indications that the psychological and physical aspects of an organism are attempting to maintain an equilibrium in order to function properly. We are interested in quantifying biopsychological stressors between mental and physical stress responses and the effect of psychosomatic influence. To analyze samples for IgA molecules levels in comparison to proclaim stress levels to determine if students are as physically stressed as they are mentally feeling stressed. Stress was reported on a zero to ten scale and these reports will be compared to actual levels of human IgA attained from saliva samples. Geospatial coordinates have been taken to relate the data to location across campus. After a regression test, showing a P value of 0.206, it was clear that there was no significant correlation in the data. This tells us that, overall, the levels of IgA, and therefore stress, did not relate to the reported level of stress from the participants.

A noninvasive cutaneous delayed type hypersensitivity test is effective for evaluating the effects of handling on immunological stress levels in rats

Rats are a common model for human physiology and psychology, yet routine handling associated with animal maintenance and treatment administration has been shown to impact behavioral and physiological measures in rats, which raises concerns about their use as a model. Adolescent and adult female rats (Sprague-Dawley, n=6 per group) were subjected to handling treatments (restraint, tickling, or playful handling) to evaluate the potential to minimize the physiological impacts of handling stress. Treatments were administered every other day for 21 days, and body weights, blood smears, and ultrasonic vocalizations were collected throughout this time and for 14 subsequent days without handling treatments. A noninvasive delayed type hypersensitivity test was performed by sensitizing rats to 2,4-Dinitrochlorobenzene on abdominal skin and later assessing the response to ear lobe exposure by measuring ear thickness. The greatest increase in lobe thickness was consistently observed at 48 hours post exposure, with few animals showing inflammation that persisted more than 72 hours. Assessments in the middle of the handling period (day 10) and at the end of the handling period (day 21) showed significantly less swelling for adolescent rats receiving the restraint treatment as compared to rats in the tickling or playful handling groups. This effect was observed in both adolescent and adult rats, however the adolescent rats showed more significant changes in circulating blood cell populations and body weight than did adults. No differences were detected outside of the handling treatment period. These results further establish that routine handling can impact immunological measures in rats and demonstrate efficacy of this noninvasive assay.

Evaluation of an automated fetal myocardial performance index

OBJECTIVE

To compare automated measurements of the fetal left myocardial performance index (MPI) with manual measurements for absolute value, repeatability and waveform acceptability.

METHODS

This was a multicenter international online study using images from uncomplicated, morphologically normal singleton pregnancies (16-38 weeks' gestation). Single Doppler ultrasound cardiac cycle images of 25 cases were selected, triplicated and randomized (n = 75). Six senior observers, unaware of the repetition of images, manually calculated MPI for each waveform and the results were compared with automation. Intraobserver repeatability and interobserver reproducibility were assessed using intraclass correlation coefficients (ICCs) and 95% CI. The agreement between each observer's manual MPI measurements and corresponding automated measurements was evaluated using Bland-Altman plots and ICCs with 95% CI. The degree of variation between experts in the classification of fetal MPI waveform quality was assessed using individual cardiac cycle left MPI images previously classified by two authors as 'optimal', 'suboptimal' or 'unacceptable', with 30 images selected for each quality group. Ten images in each category were duplicated and the resulting 120 images were randomized and then classified online by five observers. The kappa statistic (κ) was used to demonstrate interobserver and intraobserver agreement and agreement of classifications by the five observers.

RESULTS

The automated measurement software returned the same value for any given image, resulting in an ICC of 1.00. Manual measurements had intraobserver repeatability ICC values ranging from 0.69 to 0.97, and the interobserver reproducibility ICC was 0.78. Comparison of automated vs manual MPI absolute measurements for each observer gave ICCs ranging from 0.77 to 0.96. Interobserver image quality classification agreement gave k = 0.69 (P < 0.001), and the intraobserver agreement was variable (κ ranging from 0.40 to 0.81).

CONCLUSIONS

Automated fetal MPI provides superior repeatability and reproducibility to manual methodology. Additionally, experts vary significantly when classifying suitability of fetal MPI waveforms. Automated MPI may facilitate clinical translation by removing human subjectivity. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Clinical impact of improved point-of-care glucose monitoring in neonatal intensive care using Nova StatStrip: Evidence for improved accuracy, better sensitivity, and reduced test utilization

OBJECTIVES

Studies have demonstrated improved analytical performance of the Nova StatStrip glucose meter, but limited data is available on its clinical performance in critically ill neonates in the neonatal intensive care unit (NICU).

DESIGN AND METHODS

A retrospective charge review was conducted on 651 neonates admitted to the NICU over 2 years. Demographics, sample collection information, and clinical details were recorded. Glucose measurements were performed at the bedside using either the Nova StraStrip or LifeScan SureStep Flexx meters as well as corresponding measurements of laboratory venous plasma glucose. Performance was analyzed by receiver operator characteristic (ROC) curves for detecting hypoglycemia and critical glucose levels.

RESULTS

Linear regression analysis comparing StatStrip and laboratory venous plasma glucose samples demonstrated significantly tighter agreement (r(2)=0.7994) and accuracy (mean bias=0.13mmol/L) than SureStep (r(2)=0.6845 and mean bias=0.53mmol/L). StatStrip also showed improved sensitivity for detecting critical low glucose values ≤3.0mmol/L (80.9 vs 68.9%, p<0.05). ROC curve analysis further demonstrated excellent performance of StatStrip at this cutoff with an AUC of 0.98. Overall, neonates were also tested significantly less frequently with the StatStrip meter by 24% compared to SureStep.

CONCLUSIONS

Implementation of StatStrip led to better agreement with venous plasma glucose, improved detection of critical low glucose results, and more efficient test utilization. This study demonstrates the importance of accurate and sensitive glucose monitoring in the NICU.

The pro-apoptotic factor Bax regulates macrophage necrosis during Mycobacterial infection

In the zebrafish-Mycobacterium marinum model for tuberculosis infection, excess TNF triggers necrosis of infected macrophages which leads to exuberant extracellular bacterial growth and host susceptibility (Tobin et al., 2012; Roca and Ramakrishnan, 2013). It has been shown that in infected macrophages, excess TNF induces production of mitochondrial reactive oxygen species (ROS) which activate two death pathways that converge in macrophage necrosis: cyclophilin D-dependent mitochondrial transition pore and acid sphingomyelinase-dependent ceramide production that leads to lysosomal permeabilization.

In exploring the events downstream of lysosomal permeabilization, we found that ceramide acts in a Cathepsin D-dependent manner to induce cell death. In the cytosol Cathepsin D initiates the activation of pro-apoptotic factors including Bid and Bax. We engineered Bax mutants that lack its different functional domains and studied the ability of each mutant protein to regulate apoptosis and necrosis. Then we infected Bax-deficient zebrafish larvae expressing the Bax mutants that were unable to induce apoptosis. We found the BH3 domain, which is required for Bax oligomerization during apoptosis, not to be required for necrosis under excess TNF conditions. Rather, an N-terminal transmembrane helix suggested to be the first portion of Bax in contact with the mitochondrial membrane was found to be required for necrosis. Current studies are focused on understanding post-translational modifications of Bax that determine whether activation of the same protein promotes apoptosis or necrosis.

Impacts of ethanol and nicotine withdrawal on fecal immunoglobulin A levels in rats (MUC3P.947)

Alcohol and nicotine are both well known to cause depression of immune response; however, the effects of withdrawal from these substances have not been extensively explored. The impacts of exposure may arise from direct depression of the immune system or from the stress associated with exposure and withdrawal. In this study the immune response of adult male Rattus norvegicus was tested following exposure to both alcohol and nicotine, alcohol alone, nicotine alone, or neither (n=4/group). Nicotine or saline was administered 3 times per day for 10 days (0.3 mg/kg in saline; subcutaneous). Alcohol (25%w/v in nutritionally complete diet; intragastric) or isocaloric dextrose-containing diet was administered during days 7-10 of nicotine administration following the same thrice-daily schedule. Fecal samples were collected 4, 7, 11 and 14 days post exposure and fecal extractions were tested via ELISA to measure immunoglobulin A (IgA) levels. The effects of ethanol exposure, nicotine exposure, time post-exposure, and the interactions of the three were tested using a 3-way ANOVA. There was a significant decrease in IgA levels across groups on day 7 (p = 0.015), followed by an increase in IgA levels measured on day 10 in ethanol exposed groups (p = 0.011). This fluctuation in mucosal immunity following binge exposure to ethanol suggests that the impacts of even short term alcohol use impact the immune response during a withdrawal period.

Sexual functioning in military personnel: preliminary estimates and predictors

INTRODUCTION

Although the military is a young and vigorous force, service members and veterans may experience sexual functioning problems (SFPs) as a result of military service. Sexual functioning can be impaired by physical, psychological, and social factors and can impact quality of life (QOL) and happiness.

AIMS

This study aims to estimate rates and correlates of SFPs in male military personnel across demographic and psychosocial characteristics, to examine the QOL concomitants, and to evaluate barriers for treatment seeking.

METHODS

This exploratory cross-sectional study was conducted using data from a larger nationwide study conducted between October 2013 and November 2013. This sample consists of 367 male active duty service members and recent veterans (military personnel) age 40 or younger.

MAIN OUTCOME MEASURES

Erectile dysfunction (ED) was determined using the five-item International Index of Erectile Function, sexual dysfunction (SD) was determined using the Arizona Sexual Experiences Scale, Male, and QOL was determined using the World Health Organization Quality of Life, Brief.

RESULTS

SFPs were associated with various demographic, physical, and psychosocial risk factors. The rates of SD and ED were 8.45% and 33.24%, respectively, for male military personnel aged 21-40. Those who were 36-40, nonmarried, nonwhite, and of lower educational attainment reported the highest rates of SFPs. Male military personnel with poor physical and psychosocial health presented the greatest risk for ED and SD. SFPs were associated with reduced QOL and lower happiness, and barriers for treatment were generally related to social barriers.

CONCLUSIONS

SFPs in young male military personnel are an important public health concern that can severely impact QOL and happiness.

Widespread divergence between incipient Anopheles gambiae species revealed by whole genome sequences

The Afrotropical mosquito Anopheles gambiae sensu stricto, a major vector of malaria, is currently undergoing speciation into the M and S molecular forms. These forms have diverged in larval ecology and reproductive behavior through unknown genetic mechanisms, despite considerable levels of hybridization. Previous genome-wide scans using gene-based microarrays uncovered divergence between M and S that was largely confined to gene-poor pericentromeric regions, prompting a speciation-with-ongoing-gene-flow model that implicated only about 3% of the genome near centromeres in the speciation process. Here, based on the complete M and S genome sequences, we report widespread and heterogeneous genomic divergence inconsistent with appreciable levels of interform gene flow, suggesting a more advanced speciation process and greater challenges to identify genes critical to initiating that process.

A cluster of Legionnaires' disease caused by Legionella longbeachae linked to potting compost in Scotland, 2008-2009

Three cases of Legionnaires disease caused by Legionella longbeachae Sg 1 associated with potting compost have been reported in Scotland between 2008 and 2009. The exact method of transmission is still not fully understood as Legionnaires disease is thought to be acquired by droplet inhalation. The linked cases associated with compost exposure call for an introduction of compost labelling, as is already in place in other countries where L. longbeachae outbreaks have been reported.

Towards automated sleep state estimation using a Holter-oximeter

Single-channel ECG and finger photoplethysmogram were used to estimate sleep states in obstructive sleep apnea patients. Overnight Holter-oximeter recordings from 14 subjects with suspected sleep apnea were analysed. Parameters including the RR interval, photoplethysmogram amplitude and rise time, and pulse arrival time were characterised and a Hidden Markov Model classifier used to identify Wake, REM and Sleep states. An overall accuracy of 77% and Cohen's kappa of 0.54 was achieved, establishing a baseline level of usefulness for sleep state estimation using a Holter-oximeter. Autonomic arousals detected using pulse arrival time also appeared to be strongly correlated with Epworth Sleepiness Scale scores.

Incidence of childhood cancer in Switzerland: the Swiss Childhood Cancer Registry

BACKGROUND

This report describes the incidence of childhood cancer in Switzerland, based on the data from the Swiss Childhood Cancer Registry (SCCR), a national hospital-based cancer registry with very high coverage, founded in 1976 by the Swiss Paediatric Oncology Group (SPOG).

PROCEDURE

Malignancies were coded according to the International Classification of Childhood Cancer (ICCC-3). Incidence rates per 100,000 person-years were calculated for all malignancies and groups of malignancies in Swiss residents less than 15 years of age for the decade 1995-2004.

RESULTS

The SCCR annually registered on average 174 new cases of cancer in Swiss residents aged <15 years, with a median age at diagnosis of 5.6 years. The crude incidence of childhood cancer in children aged <15 years was 13.5, higher for boys (15.0 per 100,000) than for girls (12.1 per 100,000), and was nearly twice as high in the first 5 years of life (19.3 per 100,000) than in the age group 5 to 14 years (10.8 per 100,000).

CONCLUSION

Incidence of childhood cancers in the SCCR was similar to neighbouring countries and to data published by regional cancer registries in Switzerland for the same period, suggesting good completeness of registration. This makes the SCCR a valuable resource for national and international research on childhood cancer.

The frequency and impact of restless legs syndrome in primary care

This study examined the prevalence and impact of moderate to severe RLS (MS-RLS) in primary care patients in Ireland. Patients completed a screening questionnaire and those with symptoms suggestive of MS-RLS underwent a diagnostic interview. Patients diagnosed with MS-RLS completed quality of life and sleep assessment questionnaires, and their medical records were examined. Of 2628 patients screened for RLS, 74 (2.8%, 95% confidence interval 2.2%-3.5%) were ultimately diagnosed at interview as having MS-RLS. These patients reported significant impact on sleep and quality of life; 24 (32.4%) had consulted a health care professional about their RLS symptoms but only 4 (16.7%) were diagnosed with RLS. Ten (13.5%) MS-RLS patients were taking inappropriate medicines to try to relieve their symptoms. Clinically significant RLS is common in Irish general practice and has a significant effect on sleep and quality of life. Nevertheless, the condition often goes undiagnosed.

The cost of treating type 2 diabetes (CODEIRE)

Diabetes mellitus is the most common chronic metabolic disease and a major source of morbidity and mortality. Type 2 diabetes (T2D) is by far the most prevalent form of diabetes accounting for around 90% of cases worldwide. In recent years it has become apparent that a diabetes epidemic is unfolding as a result of increasing obesity, sedentary lifestyles and an ageing population. The enormity of the diabetes epidemic raises concern about the total cost to healthcare systems. This study was undertaken to investigate the direct healthcare costs of managing T2D in Ireland. Data was captured on 701 diabetes patients attending four diabetes centres. A bottom-up, prevalence-based design was used, which collected data on hospital resource use and clinical outcome measures over a 12-month period (1999/2000). The study was observational in nature, focusing on usual care of patients with T2D. Although the true prevalence of T2D in Ireland is unknown, conservative estimates are 3.9% for diagnosed diabetes and 6% for both diagnosed and undiagnosed diabetes. Using these figures the annual total direct cost was estimated at 377.2 million euro for diagnosed diabetes and 580.2 million euro for both diagnosed and undiagnosed diabetes. This corresponds to 4.1% and 6.4% of total healthcare expenditure respectively. Hospitalisations were the main driver of costs, accounting for almost half of overall costs, while ambulatory and drug costs accounted for 27% and 25% respectively. Hospitalisation costs were high because 60% of patients had developed complications. The most common microvascular and macrovascular complications were neuropathy and angina respectively. The annual cost of care for patients with microvascular and macrovascular complications were 1.8 and 2.9 times the cost of treating those without clinical evidence of complications respectively. The figure for patients with both types of complications was 3.8. This study shows that T2D is a very costly disease, largely due to the cost of and the management of complications. Many diabetes related complications are preventable, therefore it would appear a cost-effective approach for government to invest in the prevention of T2D and diabetes related complications.

Coherent combination of high-power, zigzag slab lasers

We demonstrate a scalable architecture for a high-power, high-brightness, solid-state laser based on coherent combinations of master oscillator power amplifier chains. A common master oscillator injects a sequence of multikilowatt Nd:YAG zigzag slab amplifiers. Adaptive optics correct the wavefront of each amplified beamlet. The beamlets are tiled side by side and actively phase locked to form a single output beam. The laser produces 19 kW with beam quality <2x diffraction limited. To the best of our knowledge, this is the brightest cw solid-state laser demonstrated to date.

Ensembl 2006

The Ensembl () project provides a comprehensive and integrated source of annotation of large genome sequences. Over the last year the number of genomes available from the Ensembl site has increased from 4 to 19, with the addition of the mammalian genomes of Rhesus macaque and Opossum, the chordate genome of Ciona intestinalis and the import and integration of the yeast genome. The year has also seen extensive improvements to both data analysis and presentation, with the introduction of a redesigned website, the addition of RNA gene and regulatory annotation and substantial improvements to the integration of human genome variation data.

Causative alternations of children with specific language impairment

Alternating verbs to indicate or to relinquish cause requires an understanding of semantic and syntactic knowledge. This study evaluated the ability of children with specific language impairment (SLI) to produce the causative alternation in comparison to age peers and to language peers. The children with SLI were proficient in lexically alternating verbs, yet provided fewer passive and periphrastic constructions and more different verbs and adjectival responses. Overgeneralization error data suggest that the semantic systems of some children with SLI were similar to their age comparisons. Individual differences within the SLI group suggested that some children were adept at providing syntactic responses and overgeneralizations, whereas some of the SLI group provided less mature responses of no alternations and no responses. These findings demonstrate a syntactic deficit in the causative alternation for some children with SLI.

An approach to manageable datasets in diabetes care. British Diabetic Association

A proposal is made to help the implementation of the British Diabetic Association dataset for diabetes care in those sites of care where information technology has yet to be established, or is in need of modification. A stepped approach is suggested and priorities identified.

Myocardial enlargement in defective heart development

BACKGROUND

The cardiac neural crest (neural crest extending from the mid-otic placode to the caudal region of somite 3) provides ectomesenchymal cells that contribute to aortic arch development and are essential for aortico-pulmonary septation of the outflow tract. Bilateral ablation of the cardiac neural crest in the chick embryo, prior to migration, leads to aortic arch anomalies and failure of septation of the cardiac outflow tract, which produces a severe defect known as persistent truncus arteriosus (PTA). Altered hemodynamics resulting from abnormal aortic arch artery development and PTA and other unknown factors related to the absence of neural crest, are likely to alter the developmental history of the myocardium.

METHODS

In this study the wet and dry weights of ventricles and whole embryos, the total number of myocytes per ventricle and the myocyte density (number of myocytes per unit volume of ventricular myocardium) were compared in control (unwindowed eggs), sham-operated and cardiac neural crest ablated chick embryos at day 11 of incubation.

RESULTS

We found that the wet and dry weights of ventricles from hearts with PTA were not different from normal hearts in control and sham-operated embryos. However, the embryos with PTA weighed less than embryos with normal hearts. Thus, the ventricle to embryo weight ratios were greater in embryos with PTA compared to control and sham-operated embryos for both wet (14 and 20%, respectively) and dry (30 and 59%) weights. The data further implied that more water was present with respect to body weight in comparison with sham-operated and control embryos which indicated that the embryos with PTA were edematous. The total number of myocytes and the number of myocytes per unit volume were not different when comparing sham-operated with PTA. Further, there was no indication that the myocardium from hearts with PTA was abnormal despite the small size and edema of the embryos.

CONCLUSIONS

It appears that hemodynamic stresses, resulting from the structural defects produced by neural crest ablation, are insufficient to increase heart growth, although cardiac function is depressed as evidenced by edema and failure of the embryo to thrive.

Diabetes and alternative medicine: cause for concern

'Alternative' medicines are becoming increasingly popular, and in this paper we describe our experience with alternative approaches to orthodox diabetes management. Four patients with insulin-dependent diabetes reduced or stopped their insulin in favour of therapeutic approaches including prayer, faith healing, unusual diets, and supplements of vitamins and trace elements. This resulted in ketoacidosis in three, in one case life-threatening; and weight loss and hyperglycaemia in the other. One patient developed serious retinopathy. Additionally, eight other types of alternative diabetic treatment are described, not as far as we know associated with such serious complications. These include homeopathy, reflexology, meditation, herbal treatment, 'cellular nutrition', 'subconscious healing', 'pearl therapy' (drinking milk in which pearls have been boiled) and 'astrotherapy' (typing pieces of coral around the arm). Diabetes is a chronic incurable disease, for which modern treatments remain somewhat unsatisfactory. It is therefore perhaps not surprising that some patients seek alternative treatments with more attractive claims. Diabetes health professionals need to be aware of the potential dangers associated with some of these treatments.

Insulin treatment, time-zones and air travel: a survey of current advice from British diabetic clinics

To investigate current advice given to insulin-treated diabetic patients undertaking international flights crossing time-zones, we have conducted a survey of UK physicians running diabetic clinics. Consultants were asked to give the general advice they would give to travellers on twice-daily short- and intermediate-acting insulins in four different flight situations: westward London to New York (morning and evening departures) and eastward Manchester to Singapore (morning and evening departures). Response rate was poor (37%). Six percent of replies were unhelpful (e.g. 'ring the BDA', 'carry on as usual'), and 14% liable to cause hypoglycaemia. Thirteen percent advocated change to a 'basal-bolus' system of insulin administration. The rest used variants of additional insulin for westward flights and reduced flights eastward. There was great variation in advice, and many regimens were excessively complicated. We recommend simple individualized advice, without attempts at over-zealous glycaemic control during travel. Local arrival and departure times may fit in easily with insulin and meals at standard times before and after flying, and little or no dosage alteration may be needed.

Diabetes educators international: third time lucky?

Three attempts have been made to establish an international diabetes educators network (1984, 1988, 1991). This paper outlines the early meetings, and reports on the most recent 1991 initiative and the recommendations of three education workshops held during the International Diabetes Federation Congress (IDF) in Washington, DC, 1991. As a result of the workshops, a Steering Committee was formed to determine a structure and funding for an international diabetes educators network, to foster international networking, to establish communication with the IDF, and to plan another workshop during the 15th IDF Congress in Kobe, Japan.