Acceptability and effectiveness study of therapist-assisted internet-delivered cognitive behaviour therapy for agriculture producers

Agriculture producers are less likely to seek or to receive mental health services compared to the general population. Additional research is needed to identify effective and accessible mental health interventions for this underserved population. This study used a mixed-methods approach and open trial design to examine the acceptability and effectiveness of therapist-assisted internet-delivered cognitive behaviour therapy (ICBT) supplemented with an additional agricultural resource for clients from agricultural backgrounds receiving ICBT in routine care. Clients (n = 34) participated in an online, five-lesson course that provided psychoeducation and strategies for dealing with symptoms of anxiety and depression, with weekly therapist assistance. Clients also received a tailored resource (developed with input from those with an agricultural background) providing culturally specific information and case stories pertinent to agricultural communities. Intent-to-treat analyses showed that the ICBT program was effective in reducing anxiety and depression symptoms among the agricultural population. Large within-group pre-to-post-treatment Cohen's effect sizes of d = 1.14, 95 % CI [0.41, 1.86] and d = 1.15, 95 % CI [0.42, 1.87] were found for depression and anxiety, respectively and comparable to the same program offered to the general population. Clients also experienced reductions in perceived stress and significant improvements in resiliency from pre- to post-treatment. Semi-structured interviews conducted at post-treatment with the agricultural clients (n = 31) on their experiences with ICBT identified four main themes: perceived strengths of ICBT and the tailored resource, suggestions to improve service delivery for agriculture producers, clients experienced internal and external challenges to participating in ICBT, and the positive impact of the course reached beyond the client. Very high satisfaction rates were found. These results provide support for the acceptability and effectiveness of ICBT with a tailored resource offered in routine care among agriculture producers.

Treatment outcomes for ARUBA-eligible brain arteriovenous malformations: a comparison of real-world data from the NVQI-QOD AVM registry with the ARUBA trial

BACKGROUND

Significant controversy exists about the management of unruptured cerebral arteriovenous malformations (AVMs). Results from A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) suggested that intervention increases the risk of stroke/death compared with medical management. However, numerous study limitations raised concerns about the trial's generalizability.

OBJECTIVE

To assess the rate of stroke/death and functional outcomes in ARUBA-eligible patients from a multicenter database, the Neurovascular Quality Initiative-Quality Outcomes Database (NVQI-QOD).

METHODS

We performed a retrospective analysis of prospectively collected data of ARUBA-eligible patients who underwent intervention at 18 participating centers. The primary endpoint was stroke/death from any cause. Secondary endpoints included neurologic, systemic, radiographic, and functional outcomes.

RESULTS

173 ARUBA-eligible patients underwent intervention with median follow-up of 269 (25-722.5) days. Seventy-five patients received microsurgery±embolization, 37 received radiosurgery, and 61 received embolization. Baseline demographics, risk factors, and general AVM characteristics were similar between groups. A total of 15 (8.7%) patients experienced stroke/death with no significant difference in primary outcome between treatment modalities. Microsurgery±embolization was more likely to achieve AVM obliteration (P<0.001). Kaplan-Meier survival curves demonstrated no difference in overall death/stroke outcomes between the different treatment modalities' 5-year period (P=0.087). Additionally, when compared with the ARUBA interventional arm, our patients were significantly less likely to experience death/stroke (8.7% vs 30.7%; P<0.001) and functional impairment (mRS score ≥2 25.4% vs 46.2%; P<0.01).

CONCLUSION

Our results suggest that intervention for unruptured brain AVMs at comprehensive stroke centers across the United States is safe.

Barriers and facilitators to reducing paracetamol use in low back pain: A qualitative study

BACKGROUND

Paracetamol is widely used for low back pain (LBP), but research questions its efficacy and safety. Patient education booklets have been explored for promoting deprescribing, but barriers and facilitators specific to LBP deprescribing remain unexamined.

OBJECTIVE

To identify contextual factors facilitating and obstructing successful deprescribing of paracetamol for LBP after receiving an educational booklet.

STUDY DESIGN

This study is part of an uncontrolled cohort feasibility study (CEASE NOW) in the community, recruiting from Musculoskeletal Australia and painaustralia.

PATIENT SAMPLE

Twenty-four participants with acute, sub-acute, or chronic LBP, self-reporting paracetamol consumption, were included.

METHODS

Thematic content analysis was used to analyze qualitative data on barriers and facilitators. Data were categorized by deprescribing outcomes: i) successful deprescribing, ii) attempted but failed, or iii) no attempt. Semi-structured telephone interviews were conducted within one week after each participant completed the one-month follow-up.

RESULTS

Successful deprescribing was facilitated by supportive healthcare professionals, willingness, high self-efficacy, fear of future illness, and diverse strategies for deprescribing plans. Barriers included unsupportive healthcare professionals and fear of flare-ups. Participants not attempting deprescribing believed it unnecessary, perceived it as effortful, unquestioningly trusted healthcare professionals, and lacked risk awareness.

CONCLUSIONS

Support from healthcare professionals, patient willingness, perceived necessity, risk awareness, effort, and varied strategies influence deprescribing outcomes for LBP patients using paracetamol. Addressing these factors is crucial when designing interventions to promote safe and effective deprescribing in LBP management.

Association between physical activity, sedentary behaviour and the trajectory of low back pain

BACKGROUND

Low back pain (LBP) is one of the world's most prevalent health issues. Patients with LBP experience various intensities and durations of symptoms, which can lead to distinctive course patterns commonly described as symptom trajectories.

PURPOSE

This study aimed to investigate the association between different amounts of physical activity and sedentary behavior and the trajectory of LBP, in people with a lifetime history of LBP.

STUDY DESIGN

The study involved a secondary analysis of observational longitudinal data collected from the AUstralian Twin low BACK pain (AUTBACK) study.

METHODS

A total of 329 individual twins met the inclusion criteria for analysis. Latent Class Growth Analysis was used to identify distinct patterns of LBP and select the primary outcome (probability of having a severe LBP trajectory, 0%-100%). Linear regression models were used to investigate the association between different amounts of physical activity or sedentary behavior at baseline, and the probability of having a severe LBP trajectory. Results were expressed as β coefficients and 95% confidence intervals (CI).

RESULTS

Moderate-to-vigorous intensity physical activity was significantly associated with the probability of having a severe LBP trajectory (unadjusted β -0.0276; 95%CI -0.0456 to -0.0097, p=.003). For every 1-minute increase in moderate-to-vigorous intensity physical activity per week, there was a 2.8%-point reduction in a participant's probability of having a severe LBP trajectory. No significant associations were identified between sedentary behavior or light intensity physical activity, and the probability of having a severe LBP trajectory.

CONCLUSIONS

In people with a lifetime history of LBP, engagement in higher volumes of moderate to vigorous intensity physical activity at baseline was associated with a lower probability of developing a severe trajectory of LBP over 1 year.

Comparative effectiveness of stent-assisted coiling and Woven EndoBridge embolization for the treatment of unruptured wide-neck bifurcation intracranial aneurysms

OBJECTIVE

Woven EndoBridge (WEB) intrasaccular flow disruptors and stent-assisted coiling (SAC) are viable endovascular treatment options for wide-neck bifurcation intracranial aneurysms (WNBAs). Data directly comparing these two treatment options are limited. The authors aimed to compare radiographic occlusion rates and complication profiles between patients who received WEB and those who received SAC for WNBAs.

METHODS

Retrospective review of a prospectively maintained cerebrovascular procedural database was performed at a single academic medical center between 2017 and 2021. Patients were included if they underwent WEB embolization or SAC of an unruptured WNBA. SAC patients were propensity matched to WEB-embolized patients on the basis of aneurysm morphology. Complete and adequate (complete occlusion or residual neck remnant) occlusion rates at last angiographic follow-up, as well as periprocedural complications, were compared between the two groups. A cost comparison was performed for a typical 5-mm WNBA treated with WEB versus SAC by using manufacturer-suggested retail prices.

RESULTS

Thirty-five WEB and 70 SAC patients were included. Aneurysm width, neck size, and dome-to-neck ratio were comparable between groups. Follow-up duration was significantly longer in the SAC group (median [interquartile range] 545 [202-834] days vs 228 [177-494] days, p < 0.001, Mann-Whitney U-test). Complete (66% of WEB patients vs 69% of SAC patients) and adequate (94% WEB vs 91% SAC) occlusion rates were similar between groups at the last available angiographic follow-up (p = 0.744, chi-square test). Complete occlusion rates were comparable on Cox regression analysis after correction for follow-up duration (hazard ratio 1.5, 95% CI 0.8-3.1). Average time to residual aneurysm or neck formation was not statistically different between treatment groups (613 days for SAC patients vs 347 days for WEB patients, p = 0.225, log-rank test). Periprocedural complications trended higher in the SAC group (0% WEB vs 9% SAC, p = 0.175, Fisher exact test), although this finding was not significant. The equipment costs for a typical SAC case were estimated at $18,950, whereas the costs for a typical WEB device case were estimated at $18,630.

CONCLUSIONS

Midterm complete and adequate occlusion rates were similar between patients treated with WEB and those treated with SAC. Given these comparable outcomes, there may be equipoise in treatment options for WNBAs.

Diagnostic yield of cerebral angiography for intracranial hemorrhage in young patients: A single-center retrospective analysis

BACKGROUND

Intracranial hemorrhage (ICH) secondary to hypertension (HTN) classically occurs in the basal ganglia, cerebellum, or pons. Vascular lesions such as aneurysms or arteriovenous malformations (AVMs) are more common in younger patients. We investigated the utility of diagnostic subtraction angiography (DSA) in young hypertensive patients with non-lobar ICH.

METHODS

A retrospective review (2013-2022) identified young (18-60 years) patients who underwent DSA for ICH. HTN history, ICH location, presence/absence of subarachnoid hemorrhage (SAH), and computed tomography angiography (CTA) findings were collected. The main outcome was DSA-positivity, defined as presence of an AVM, aneurysm, Moyamoya disease, reversible cerebral vasoconstriction syndrome, or dural arteriovenous fistula on DSA.

RESULTS

Two hundred sixty patients were included, and the DSA-positivity rate was 19%.DSA-positivity was lower in hypertensive patients with ICHs in the cerebellum, pons, or basal ganglia compared to the rest of the patient sample (9% vs 26%, p = 0.0002, Fisher's exact test). We developed the ICH-Angio score (0-5 points) based on CTA findings, ICH location, HTN history, and presence of SAH to predict risk of underlying vascular lesions. DSA-positivity was lower in those with a score of 0 (0/62; 0%) compared to a score of 1 (5/52; 10%), 2 (17/48; 35%), 3 (10/20; 50%), 4 (5/6; 83%), or 5 (3/3; 100%).

CONCLUSION

The ICH-Angio score was able to non-invasively rule out an underlying vascular etiology for ICH in up to one-third of patients. HTN, ICH location, CTA findings, and associated SAH can identify patients at low risk for harboring underlying vascular lesions.

(C)onsumer focused (E)ducation on p(A)racetamol (S)ide (E)ffects, i(N)adequate (O)utcomes and (W)eaning (CEASE NOW) for individuals with low back pain: results of a feasibility study

OBJECTIVES

To determine the feasibility of a patient-education booklet to support patients with low back pain (LBP) to reduce paracetamol intake.

DESIGN

Single group, repeated measures feasibility study.

SETTING

Community.

PARTICIPANTS

Adults experiencing LBP of any kind and self-reporting consumption of paracetamol for LBP weekly for at least 1 month were invited to participate.

INTERVENTION

Participants received a patient-education booklet 1 week after the baseline measures were collected. The intervention was designed to change beliefs, increase knowledge and self-efficacy to deprescribe paracetamol for their LBP and create discussion with a health professional through the mechanisms of motivation, capacity and opportunity.

PRIMARY OUTCOME MEASURES

Feasibility of recruitment procedures, data collection and acceptability of the intervention.

SECONDARY OUTCOME MEASURES

Changes in motivation, self-efficacy, opportunity to deprescribe paracetamol for their LBP, paracetamol usage and LBP clinical outcomes at baseline, 1-week and 1-month follow-up.

RESULTS

A total of 24 participants were recruited into the study within the timeframe of 3 months from study advertisement and all completed the study follow-up. There were no missing data for any outcome measure across all follow-up points, 22 (91.6%) participants were willing to participate in a future randomised control trial (RCT) and over 60% of participants responded positively to questions regarding acceptability of the patient-educational booklet. Overall, at the 1-month follow-up, approximately two thirds (15/24) of participants had an increase in motivation and self-efficacy scores and had discussed or intended to discuss their paracetamol use for LBP with a health professional.

CONCLUSIONS

The results of this study demonstrate that the patient-education booklet is feasible to implement, and both the intervention and study design were well-received by participants. This study supports the undertaking an RCT to assess the effects of the patient-education booklet on deprescribing paracetamol in people with LBP.

The impact of different intensities and domains of physical activity on analgesic use and activity limitation in people with low back pain: a prospective cohort study with a one-year follow-up

BACKGROUND

Analgesics are the most common form of managing low back pain (LBP). No previous study has examined which domains and intensities of physical activity are most beneficial in reducing the frequency of analgesic use for LBP, and its related activity limitation.

METHODS

This cohort study forms part of the AUstralian Twin low BACK pain study, investigating the impact of physical activity on LBP. Information on demographics, LBP and health-related factors, including physical activity were collected at baseline. Data on the total counts of analgesic use and activity limitation for LBP were collected weekly for one-year. Negative binomial regression models were conducted separately for each type of physical activity. Results were presented as Incidence Rate Ratios (IRR) and 95% Confidence Intervals (CI).

RESULTS

From an initial sample of 366 participants, 86 participants reported counts of analgesic use and 140 recorded counts of activity limitation across the follow up period. The negative binomial regression models for analgesic use counts indicated moderate-vigorous physical activity (IRR 0·97, 95% C.I 0·96-0·99) and physical workload (IRR 1·02, 95% C.I 1·01-1·05) to be significant. For activity limitation counts, significant associations were shown for sedentary time (IRR 1·04, 95% C.I 1·01-1·09) and leisure activity (IRR 0·94, 95% C.I 0·81-0·99).

CONCLUSIONS

Our findings highlight the potential importance of supporting engagement in moderate-vigorous and leisure physical activity, as well as minimising sedentary time and physical workload to reduce the risk of activity limitation and the need for analgesic use in people with LBP.

MASTREE+: Time-series of plant reproductive effort from six continents

Significant gaps remain in understanding the response of plant reproduction to environmental change. This is partly because measuring reproduction in long-lived plants requires direct observation over many years and such datasets have rarely been made publicly available. Here we introduce MASTREE+, a data set that collates reproductive time-series data from across the globe and makes these data freely available to the community. MASTREE+ includes 73,828 georeferenced observations of annual reproduction (e.g. seed and fruit counts) in perennial plant populations worldwide. These observations consist of 5971 population-level time-series from 974 species in 66 countries. The mean and median time-series length is 12.4 and 10 years respectively, and the data set includes 1122 series that extend over at least two decades (≥20 years of observations). For a subset of well-studied species, MASTREE+ includes extensive replication of time-series across geographical and climatic gradients. Here we describe the open-access data set, available as a.csv file, and we introduce an associated web-based app for data exploration. MASTREE+ will provide the basis for improved understanding of the response of long-lived plant reproduction to environmental change. Additionally, MASTREE+ will enable investigation of the ecology and evolution of reproductive strategies in perennial plants, and the role of plant reproduction as a driver of ecosystem dynamics.

Survival Outcomes Following Discontinuation of Ipilimumab and Nivolumab for Advanced Melanoma in a Population-based Cohort

AIMS

Induction ipilimumab and nivolumab followed by maintenance nivolumab improve overall survival compared with ipilimumab alone in patients with advanced melanoma, but immune-related adverse events (irAE) occur commonly. The need for induction discontinuation because of irAE and the relationship between irAE and survival in non-trials patients are unclear.

MATERIALS AND METHODS

Patients with unresectable stage III-IV melanoma receiving first-line combination immunotherapy at one of six centres between December 2017 and February 2020 outside of trials were identified retrospectively. Landmark 12-week Kaplan-Meier analyses and log-rank tests were used to evaluate associations between discontinuation of induction therapy on overall survival and time to treatment failure (TTF). Multivariable analysis of factors influencing overall survival and TTF was undertaken.

RESULTS

Among 95 patients, the median age was 62 years, 38.9% had Eastern Cooperative Oncology Group performance status ≥1 and 22.1% had brain metastases. The median follow-up for the whole cohort was 19.8 months by the reverse Kaplan-Meier method. Any grade and grade 3-4 irAE were noted in 78.9% and 44.2% of the cohort, respectively. 44.2% of patients completed induction immunotherapy, whereas 41.1% did not due to irAE. Twelve-week landmark overall survival and TTF were similar in patients who completed induction versus those who did not due to irAE. On multivariable analysis, any grade irAE (versus none) was associated with longer overall survival (hazard ratio = 0.35, 95% confidence interval 0.15-0.82, P = 0.02) and TTF (hazard ratio = 0.38, 95% confidence interval = 0.17-0.81, P = 0.01). Grade 3-4 irAE correlated with longer TTF (hazard ratio = 0.45, 95% confidence interval = 0.20-1.01, P = 0.05).

CONCLUSION

In this population-based cohort, discontinuation of induction immunotherapy as a result of irAE did not adversely affect overall survival or TTF. irAE observed during ipilimumab and nivolumab induction were associated with improved survival outcomes.

Patient consent in emergency cardiovascular medicine: lessons from the ARREST trial in out-of-hospital cardiac arrest

Introduction

Randomised trials in emergency cardiovascular medicine are challenging but vital for improving patient care. Obtaining informed consent in such an environment is a particular issue and can be controversial. The ARREST trial is assessing whether out-of-hospital cardiac arrest patients without an obvious cause should be taken to a specialist heart centre or the closest emergency department in London, UK. This patient group presents specific difficulties: patients lack capacity to consent, presentation is unpredictable, care must not be delayed, and mortality rates can be &gt;50%.

Purpose

Within existing consent and methodological frameworks we aimed to design a randomised clinical trial to pragmatically, safely and ethically recruit cardiac arrest patients pre-hospital.

Methods

During the set-up of ARREST we accessed the following sources of information: 1) ARREST research team; 2) cardiovascular patient groups; 3) researchers running similar trials; 4) regulatory bodies; and, 5) published literature on research in emergency contexts. The information that we collected guided the design of the trial with a focus on patient consent, documentation and follow-up.

Results

The ARREST trial uses deferred consent with remote online randomisation to enrol patients without delaying care. To minimise the risk of bias, baseline and primary endpoint data are collected on patients who die or are discharged prior to consent. Remote follow-up using electronic health records reduces the burden on the patients and researchers. Full ethical approval was received in January 2018 and the first patient was enrolled in February 2018. ARREST is recruiting to target and is on track to finish within the projected timelines.

Conclusions

Deferred consent has been key to the success of ARREST and patients have been receptive. However, further research into the experience of patients in emergency cardiovascular medicine trials using deferred consent is needed to better understand when it is an appropriate model. More broadly, there is a shortfall in high quality research in challenging environments such as emergency cardiovascular care. Innovation in consent methods and proportional research governance would facilitate higher quality research and benefit patient care.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation

Dynamics and Dispersal of Local HIV Epidemics Within San Diego and Across The San Diego-Tijuana Border

BACKGROUND

Evolutionary analyses of well-annotated HIV sequence data can provide insights into viral transmission patterns and associated factors. Here, we explored the transmission dynamics of the HIV-1 subtype B epidemic across the San Diego (US) - Tijuana (Mexico) border region to identify factors that could help guide public health policy.

METHODS

HIV pol sequences were collected from people with HIV in San Diego County and from Tijuana between 1996-2018. A multistep phylogenetic approach was used to characterize the dynamics of spread. The contribution of geospatial factors and HIV risk group to the local dynamics were evaluated.

RESULTS

Phylogeographic analyses of the 2,034 sequences revealed an important contribution of local transmission in sustaining the epidemic, as well as a complex viral migration network across the region. Geospatial viral dispersal between San Diego communities occurred predominantly among men-who-have-sex with-men with central San Diego being the main source (34.9%) and recipient (39.5%) of migration events. HIV migration was more frequent from San Diego county towards Tijuana than vice versa. Migrations were best explained by driving time between locations.

CONCLUSION

The US-Mexico border may not be a major barrier to the spread of HIV, which may stimulate coordinated transnational intervention approaches. Whereas a focus on central San Diego has the potential to avert most spread, the substantial viral migration independent of central San Diego shows that county-wide efforts will be more effective. Combined, this work shows that epidemiological information gleaned from pathogen genomes can uncover mechanisms that underlie sustained spread and, in turn, can be a building block of public health decision making.

Correction to: Factors Associated with Mood Disorder Diagnosis Among a Population Based Cohort of Men and Women Living With and Without HIV in British Columbia Between 1998 and 2012

Using data from the Comparison of Outcomes and Service Utilization Trends (COAST) study we examined factors associated with mood disorder diagnosis (MDD) among people living with HIV (PLHIV) and HIV-negative individuals in British Columbia, Canada. MDD cases were identified between 1998 and 2012 using International Classification of Disease 9 and 10 codes. A total of 491,796 individuals were included and 1552 (23.7%) and 60,097 (12.4%) cases of MDD were identified among the HIV-positive and HIV-negative populations, respectively. Results showed HIV status was associated with greater odds of MDD among men and lower odds among women. Among PLHIV, MDD was significantly associated with: identifying as gay, bisexual or other men who have sex with men compared to heterosexuals; higher viral load; history of injection drug use; and concurrent anxiety, dysthymia, and substance use disorders. Findings highlight the need for comprehensive and holistic HIV and mental health care.

P6484Invasive and non-invasive characterisation of low gradient aortic stenosis

Background

Low gradient severe aortic stenosis (LGAS) is associated with unfavourable outcomes when compared to high gradient aortic stenosis (HGAS), yet the contributing pathophysiology is poorly understood.

Methods

Symptomatic LGAS and HGAS patients undergoing trans-catheter aortic valve implantation (TAVI) underwent 3T stress perfusion cardiac magnetic resonance imaging (CMR) pre-(within 24 hours) and post-(4–6 months) TAVI. Left ventricular (LV) contractility and coronary flow/pressure were measured during hyperaemia and rapid pacing, immediately before and after TAVI, using a conductance LV catheter and dual-pressure and Doppler sensor–tipped guidewire in the mid-left anterior descending coronary artery.

Results

24 patients were recruited resulting in 19 suitable datasets (LGAS N=9, HGAS N=10, equally matched for comorbidities and B-natriuretic peptide level). LGAS patients had a smaller LV end diastolic volume index (p=0.035) and lower LV mass index (LVMI) (p=0.037). Pre-TAVI stress global endocardium-epicardium gradient was 0.88±0.09 and global myocardial perfusion reserve (MPR) 2.0±0.48 in 14 patients (6 LGAS and 8 HGAS patients, no difference between groups). Pre-TAVI, baseline coronary data demonstrated lower augmentation pressure (AP, p=0.035) and augmentation index (AIx, p=0.02) in the LGAS group. LGAS patients also exhibited a shorter ejection time (p=0.015), larger forward compression waves during rest, hyperaemia and rapid pacing, and smaller backward expansion waves (BEW) (p=0.001). Lower baseline end systolic pressure (p=0.004), inotropy (dP/dt+, p=0.045), lusitropy (dP/dt-, p=0.069), and stroke work (p=0.019) were observed in the LGAS group. Whilst LV size was smaller the LGAS group, rapid pacing induced a more significant drop in end systolic volume (p=0.045) and ejection fraction (p=0.015) in patients with HGAS. Post-TAVI, the hyperaemic BEW fell sharply (p<0.001), along with coronary VTI (p=0.02), and average pulse velocity (p=0.028), and AP and AIx remained lower (p=0.034 and p=0.031, respectively). The forward expansion wave was reduced in LGAS during rapid pacing. The HGAS group displayed a more profound drop in dP/dt+ (p=0.011) and dP/dt- p=0.014) at rest following intervention. Repeat CMR demonstrated statistically significant reduction in LV size and LVMI (p=0.012 and p<0.001, respectively) with significant increase in 3D global peak radial, circumferential and longitudinal strain (p=0.004, p=0.001 and p=0.018, respectively). Post-TAVI stress global endocardium-epicardium gradient was 0.88±0.13 and MPR 2.46±0.59 (improved from pre-TAVI, p=0.05). There was no difference in remodelling patterns or perfusion between the two groups.

Conclusion

This is the first study detailing the combined invasive and CMR pathophysiological changes in LGAS. Despite invasive parameters indicating a disease of less severe AS, the level of perfusion abnormality is disproportionate which may in part, relate to their adverse prognosis.

Acknowledgement/Funding

This research is funded by a Clinical Research Training Fellowship grant from the British Heart Foundation (FS/16/51/32365).

The Role of Gender in the Health and Human Rights Practices of Police: The SHIELD Study in Tijuana, Mexico

Globally, punitive drug law enforcement drives human rights violations. Drug control tactics, such as syringe confiscation and drug-related arrests, also cascade into health harms among people who use drugs. The role of police officer characteristics in shaping such enforcement and measures to reform police practices remains underexamined. We evaluated gender differences in syringe confiscation and syringe-related arrest behaviors among municipal police officers in Tijuana, Mexico, where syringe possession is legal. In the context of the SHIELD Study focusing on aligning policing with harm reduction measures, our baseline sample covered municipal police officers who reported having occupational contact with syringes. We used multivariable logistic regression with robust variance estimation via a generalized estimating equation to identify correlates of syringe-related policing behaviors. Among respondent officers (n=1,555), 12% were female. After considering possible confounding variables, such as district of service and work experience, female officers were significantly less likely to report confiscating syringes or arresting individuals for syringe possession. Consideration of officer gender is important in the design of interventions to improve the health and human rights of people who inject drugs and other highly policed groups, as well as measures to safeguard officer occupational safety. The feminization of law enforcement deserves special consideration as an imperative in reducing the public health harms of policing.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Investigating small molecules to inhibit germinal center kinase-like kinase (GLK/MAP4K3) upstream of PKCθ phosphorylation: Potential therapy to modulate T cell dependent immunity

Germinal center kinase-like kinase (GLK, also known as MAP4K3) has been hypothesized to have an effect on key cellular activities, including inflammatory responses. GLK is required for activation of protein kinase C-θ (PKCθ) in T cells. Controlling the activity of T helper cell responses could be valuable for the treatment of autoimmune diseases. This approach circumvents previous unsuccessful approaches to target PKCθ directly. The use of structure based drug design, aided by the first crystal structure of GLK, led to the discovery of several inhibitors that demonstrate potent inhibition of GLK biochemically and in relevant cell lines.

Factors Associated with Mood Disorder Diagnosis Among a Population Based Cohort of Men and Women Living With and Without HIV in British Columbia Between 1998 and 2012

Using data from the Comparison of Outcomes and Service Utilization Trends (COAST) study we examined factors associated with mood disorder diagnosis (MDD) among people living with HIV (PLHIV) and HIV-negative individuals in British Columbia, Canada. MDD cases were identified between 1998 and 2012 using International Classification of Disease 9 and 10 codes. A total of 491,796 individuals were included and 1552 (23.7%) and 60,097 (12.4%) cases of MDD were identified among the HIV-positive and HIV-negative populations, respectively. Results showed HIV status was associated with greater odds of MDD among men and lower odds among women. Among PLHIV, MDD was significantly associated with: identifying as gay, bisexual or other men who have sex with men compared to heterosexuals; higher viral load; history of injection drug use; and concurrent anxiety, dysthymia, and substance use disorders. Findings highlight the need for comprehensive and holistic HIV and mental health care.

Validation of the tablet-administered Brief Assessment of Cognition (BAC App)

Computerized tests benefit from automated scoring procedures and standardized administration instructions. These methods can reduce the potential for rater error. However, especially in patients with severe mental illnesses, the equivalency of traditional and tablet-based tests cannot be assumed. The Brief Assessment of Cognition in Schizophrenia (BACS) is a pen-and-paper cognitive assessment tool that has been used in hundreds of research studies and clinical trials, and has normative data available for generating age- and gender-corrected standardized scores. A tablet-based version of the BACS called the BAC App has been developed. This study compared performance on the BACS and the BAC App in patients with schizophrenia and healthy controls. Test equivalency was assessed, and the applicability of paper-based normative data was evaluated. Results demonstrated the distributions of standardized composite scores for the tablet-based BAC App and the pen-and-paper BACS were indistinguishable, and the between-methods mean differences were not statistically significant. The discrimination between patients and controls was similarly robust. The between-methods correlations for individual measures in patients were r>0.70 for most subtests. When data from the Token Motor Test was omitted, the between-methods correlation of composite scores was r=0.88 (df=48; p<0.001) in healthy controls and r=0.89 (df=46; p<0.001) in patients, consistent with the test-retest reliability of each measure. Taken together, results indicate that the tablet-based BAC App generates results consistent with the traditional pen-and-paper BACS, and support the notion that the BAC App is appropriate for use in clinical trials and clinical practice.

The epidemiology and outcomes of invasive Candida infections among organ transplant recipients in the United States: results of the Transplant-Associated Infection Surveillance Network (TRANSNET)

BACKGROUND

Invasive candidiasis (IC) is a common cause of mortality in solid organ transplant recipients (OTRs), but knowledge of epidemiology in this population is limited.

METHOD

The present analysis describes data from 15 US centers that prospectively identified IC from nearly 17 000 OTRs. Analyses were undertaken to determine predictors of infection and mortality.

RESULTS

A total of 639 cases of IC were identified. The most common species was Candida albicans (46.3%), followed by Candida glabrata (24.4%) and Candida parapsilosis (8.1%). In 68 cases >1 species was identified. The most common infection site was bloodstream (44%), followed by intra-abdominal (14%). The most frequently affected allograft groups were liver (41.1%) and kidney (35.3%). All-cause mortality at 90 days was 26.5% for all species and was highest for Candida tropicalis (44%) and C. parapsilosis (35.2%). Non-white race and female gender were more commonly associated with non-albicans species. A high rate of breakthrough IC was seen in patients receiving antifungal prophylaxis (39%). Factors associated with mortality include organ dysfunction, lung transplant, and treatment with a polyene antifungal. The only modifiable factor identified was choice of antifungal drug class based upon infecting Candida species.

CONCLUSION

These data highlight the common and distinct features of IC in OTRs.

Surveillance for Heartland Virus (Bunyaviridae: Phlebovirus) in Missouri During 2013: First Detection of Virus in Adults of Amblyomma americanum (Acari: Ixodidae)

During 2013, we collected and tested ticks for Heartland virus (HRTV), a recently described human pathogen in the genus Phlebovirus (Bunyaviridae), from six sites in northwestern Missouri. Five sites were properties owned by HRTV patients, and the sixth was a conservation area that yielded virus in ticks during 2012. We collected 39,096 ticks representing five species; however, two species, Amblyomma americanum (L.) (97.6%) and Dermacentor variabilis (Say) (2.3%), accounted for nearly all ticks collected. We detected 60 HRTV-positive tick pools and all were composed of A americanum: 53 pools of nymphs, six pools of male adults, and one pool of female adults. This is the first record of HRTV in adult ticks. Virus was detected at five properties that yielded A. americanum ticks, including properties owned by four of five patients. Virus was detected at two sites that yielded virus in 2012. Detection of virus in multiple years indicates that the virus persists in ticks within a relatively small geographic area, although infection rates (IR) may vary greatly among sites and between years at a site. IR per 1,000 A. americanum in northwestern Missouri during the April-July 2013 study period were as follows: all adults, IR = 1.13; adult females, IR = 0.33; adult males, IR = 1.90; and nymphs, IR = 1.79. The IR in nymphs, the stage with the largest data set, corresponds to 1/559 infected ticks. Having robust estimates of IR in various stages for A. americanum should lead to more accurate public health messaging and a better understanding of virus transmission.

Identification of a New Class of Antifungals Targeting the Synthesis of Fungal Sphingolipids

Recent estimates suggest that >300 million people are afflicted by serious fungal infections worldwide. Current antifungal drugs are static and toxic and/or have a narrow spectrum of activity. Thus, there is an urgent need for the development of new antifungal drugs. The fungal sphingolipid glucosylceramide (GlcCer) is critical in promoting virulence of a variety of human-pathogenic fungi. In this study, we screened a synthetic drug library for compounds that target the synthesis of fungal, but not mammalian, GlcCer and found two compounds [N'-(3-bromo-4-hydroxybenzylidene)-2-methylbenzohydrazide (BHBM) and its derivative, 3-bromo-N'-(3-bromo-4-hydroxybenzylidene) benzohydrazide (D0)] that were highly effective in vitro and in vivo against several pathogenic fungi. BHBM and D0 were well tolerated in animals and are highly synergistic or additive to current antifungals. BHBM and D0 significantly affected fungal cell morphology and resulted in the accumulation of intracellular vesicles. Deep-sequencing analysis of drug-resistant mutants revealed that four protein products, encoded by genes APL5, COS111, MKK1, and STE2, which are involved in vesicular transport and cell cycle progression, are targeted by BHBM.

IMPORTANCE

Fungal infections are a significant cause of morbidity and mortality worldwide. Current antifungal drugs suffer from various drawbacks, including toxicity, drug resistance, and narrow spectrum of activity. In this study, we have demonstrated that pharmaceutical inhibition of fungal glucosylceramide presents a new opportunity to treat cryptococcosis and various other fungal infections. In addition to being effective against pathogenic fungi, the compounds discovered in this study were well tolerated by animals and additive to current antifungals. These findings suggest that these drugs might pave the way for the development of a new class of antifungals.

Temporal macrodynamics and microdynamics of the postoperative impedance at the tissue-electrode interface in deep brain stimulation patients

OBJECTIVE

To study the temporal dynamics of tissue impedance after deep brain stimulation (DBS).

BACKGROUND

DBS therapy commonly employs a constant voltage approach, and current delivery to the tissue is a function of electrode-tissue impedance. It is presumed that impedance fluctuates early postimplantation, with implications for variations in current delivery and therapeutic efficacy. We hypothesised that the largest variation will be recorded early after surgery, followed by stabilisation.

METHODS

Review of impedance checks of implanted DBS systems at standard parameters during the first five months postimplantation. All measurement time points were binned into 1-week periods, and we used repeated measures analysis of variance with Tukey pairwise multiple comparisons correction. The analysis was repeated after normalising impedance values for each subject to that patient's baseline value.

RESULTS

There was an initial (non-significant) drop in impedance at week 1, followed by significant increase at week 3 (p=0.0002). There were no further significant differences in impedance values at subsequent time points. Analysis of normalised data showed a significant difference between the initial measurement in postoperative week 1 (normalised value 1) and week 3 (normalised value 1.73, p<0.0001), with no further difference among the subsequent weekly points during the 5-month follow-up. No significant hourly variations were found at any time points.

CONCLUSIONS

We found major changes in impedance within the first month postimplantation, with no further variation. This is an important confirmation in patients of this temporal dynamics of the impedance of implanted DBS hardware, with potential therapeutic implications.

A truncated FatB resulting from a single nucleotide insertion is responsible for reducing saturated fatty acids in maize seed oil

We identified a G-nucleotide insertion in a maize FatB responsible for reducing saturated fatty acids through QTL mapping and map-based cloning and developed an allele-specific DNA marker for molecular breeding. Vegetable oils with reduced saturated fatty acids have signficant health benefits. SRS72NE, a Dow AgroSciences proprietory maize inbred line, was found to contain signficantly reduced levels of palmitic acid and total saturated fatty acids in seed oil when compared to other common inbreds. Using F2 and F3 populations derived from a cross between SRS72NE and a normal inbred SLN74, we have demonstrated that the reduced saturated fatty acid phenotype in SRS72NE is controlled by a single QTL on chromosome 9 that explains 79.1 % of palmitic acid and 79.6 % total saturated fatty acid variations. The QTL was mapped to an interval of 105 kb that contains one single gene, a type B fatty acyl-ACP thioesterase (ZmFatB; GRMZM5G829544). ZmFatB alleles from SRS72NE and common inbreds were cloned and sequenced. SRS72NE fatb allele contains a single nucleotide (G) insertion in the 6th exon, which creates a premature stop codon 22 base pairs down stream. As a result, ZmFatB protein from SRS72NE is predicted to contain eight altered and 90 deleted amino acids at its C-terminus. Because the affected region is part of the conserved acyl-ACP thioesterase catalytic domain, the truncated ZmFatB in SRS72NE is likely non-functional. We also show that fatb RNA level in SRS72NE is reduced by 4.4-fold when compared to the normal allele SNL74. A high throughput DNA assay capable of differentiating the normal and reduced saturate fatty acid alleles has been developed and can be used for accelerated molecular breeding.

Examining the evidence on the causal effect of HAART on transmission of HIV using the Bradford Hill criteria

In recent years, evidence has accumulated regarding the ability of HAART to prevent HIV transmission. Early supportive evidence was derived from observational, ecological and population-based studies. More recently, a randomized clinical trial showed that immediate use of HAART led to a 96% decrease in HIV transmission events within HIV serodiscordant heterosexual couples. However, the generalizability of the effect of HAART, and the population-level impact on HIV transmission continues to generate substantial debate. We, therefore, conducted a review of the evidence regarding the preventive effect of HAART on HIV transmission within the context of the Bradford Hill criteria for causality. Taken together, we find the accumulated evidence supporting HIV treatment as prevention meets each of the Bradford Hill criteria for causality. We conclude that the opportunity cost of inaction while waiting for additional evidence on the generalizability of effect in other risk groups is too high. Efforts should be redoubled to mobilize the financial capital and political will to optimize implementation of HIV Treatment as Prevention strategies on a wide scale.

Systematic review of cognitive development across childhood in Down syndrome: implications for treatment interventions

BACKGROUND

There is conjecture regarding the profile of cognitive development over time in children with Down syndrome (DS). Characterising this profile would be valuable for the planning and assessment of intervention studies.

METHOD

A systematic search of the literature from 1990 to the present was conducted to identify longitudinal data on cognitive trajectories in children with DS.

RESULTS

Thirteen studies were identified: six assessed overall cognitive performance and seven assessed specific cognitive domains. Studies assessing IQ reported a decline across time. Studies assessing change in cognitive domains were, for the most part, not interpretable because of large age ranges in samples obscuring age-specific data.

CONCLUSION

The current literature has only begun to describe typical cognitive developmental trajectories in children with DS; additional research is needed to clarify this topic.

A comparison of psychosocial outcomes in elderly Alzheimer caregivers and noncaregivers

OBJECTIVE

To conduct an analysis of the stress, coping, and mood consequences of Alzheimer caregiving.

DESIGN

Cross-sectional.

SETTING

Community-based study.

PARTICIPANTS

Sample included 125 Alzheimer caregivers and 60 demographically similar older adults with nondemented spouses (i.e., noncaregivers).

MEASUREMENTS

We compared caregivers and noncaregivers on stress, coping, and mood outcomes. We also examined antidepressant use within the caregiver sample. An emphasis was placed upon effect size differences, including Cohen's d as well as more clinically meaningful effect sizes.

RESULTS

Caregivers were significantly more likely to endorse depressive symptoms and to meet clinically significant cutoff for depression (40% for caregivers; 5% for noncaregivers). Approximately 25% of caregivers reported taking antidepressant medication, although 69% of these continued to experience significant symptoms of depression. Caregivers also utilized fewer positive coping and greater negative coping strategies than noncaregivers.

CONCLUSION

The number of caregivers will increase dramatically over the next two decades, and caregivers will likely seek care from primary care providers. We provide an overview of the psychological issues facing caregivers so that effective screening and treatment may be recommended.

Transcriptional activation of Brassica napus β-ketoacyl-ACP synthase II with an engineered zinc finger protein transcription factor

Targeted gene regulation via designed transcription factors has great potential for precise phenotypic modification and acceleration of novel crop trait development. Canola seed oil composition is dictated largely by the expression of genes encoding enzymes in the fatty acid biosynthetic pathway. In the present study, zinc finger proteins (ZFPs) were designed to bind DNA sequences common to two canola β-ketoacyl-ACP Synthase II (KASII) genes downstream of their transcription start site. Transcriptional activators (ZFP-TFs) were constructed by fusing these ZFP DNA-binding domains to the VP16 transcriptional activation domain. Following transformation using Agrobacterium, transgenic events expressing ZFP-TFs were generated and shown to have elevated KASII transcript levels in the leaves of transgenic T(0) plants when compared to 'selectable marker only' controls as well as of T(1) progeny plants when compared to null segregants. In addition, leaves of ZFP-TF-expressing T(1) plants contained statistically significant decreases in palmitic acid (consistent with increased KASII activity) and increased total C18. Similarly, T(2) seed displayed statistically significant decreases in palmitic acid, increased total C18 and reduced total saturated fatty acid contents. These results demonstrate that designed ZFP-TFs can be used to regulate the expression of endogenous genes to elicit specific phenotypic modifications of agronomically relevant traits in a crop species.

Snapshot prevalence and characterization of Staphylococcus species, including MRSA, in a student athletic facility: an undergraduate research project

OBJECTIVE

To evaluate and characterize the prevalence of MRSA, Staphylococcus aureus, and other Staphylococcus species found on exercise equipment on one day point of collection.

DESIGN

A cross sectional, point prevalence design (pilot study) with a single time of measurement. Data collected in summer of 2011 (Undergraduate Research Project for CLS Program, CLS 4361 Clinical Research). Project received Institutional Review Board exemption.

SETTING

In a higher education athletic facility in Texas.

SAMPLES

One hundred twenty-five environmental samples were collected from various exercise equipment and areas within the facility.

MAIN OUTCOME MEASURES

Samples were screened for Staphylococcus species using standard microbiological techniques. Confirmation of S. aureus was conducted by DRYSPOT Staphytect Plus. MRSA isolates were confirmed with CHROMagar; VITEK 2 antibiotic susceptibility testing and PFGE characterized all MRSA isolates.

RESULTS

Prevalence of MRSA was 6%, S. aureus 38%, other Staphylococcus species 52% and no growth 4%. Prevalence of S. aureus and MRSA was highest on free weights and mats, respectively. PFGE characterized all MRSA isolates as HA-MRSA (USA100 strain).

CONCLUSIONS

Although limitations exist for this study with a single time of measurement for data, the findings indicate potential exposure risks from Staphylococcus species in college athletic facilities. Compliance (disinfection) and creative health education may reduce transmission of pathogens, environmental load, and incidence of colonization or infection in students.

Brainstem origins of the n18 component of the somatosensory evoked response

Proposed generator sites for the N18 component of the somatosensory evoked potential (SEP) range in location from the medulla to the thalamus. Additional knowledge regarding the generators of the N18 will be important in interpreting the results of intra-operative monitoring during skull base surgery and providing the surgeon more specific information. The goal of this study was to use both intracranial electrical recording and the effects of acute brainstem ischemia in humans to further define the generators of N18. Monopolar electrodes were used to record SEP (after median nerve stimulation) from the brainstem surface in eight patients undergoing posterior fossa surgical procedures. Recordings were made from various locations, from the cervico-medullary junction to the level of the aqueduct of Sylvius. As the electrode moved rostrally on the brainstem surface, the difference in latencies between the scalp N18 potential and the electrode potential approached zero, suggesting an upper pontine-lower midbrain origin of the N18 potential. These findings were supported by the lack of change in the N18 potentials of ten patients with basilar tip aneurysms who experienced marked changes of their N20/P22 potentials during temporary occlusion of the distal basilar artery.