bluuebunny/crossref_metadata_2025 huggingface dataset:
Timing of Intradermal Rabies Pre-exposure Prophylaxis Injections: Immunological Effect on Vaccination Response
Authors: Van Nieuwenhove Mathias D M , Damanet Benjamin , Soentjens Patrick
Published: April 2019

Introduction

Rabies remains a global threat, with annually over 59,000 deaths. Intradermal (ID) pre-exposure prophylaxis (PrEP) is very efficient and reduces the need for rabies immunoglobulins. Not much is known about factors that influence the immune response to ID administered rabies vaccine. The aim of this study is to determine if variations in timing of vaccine administration and serology determination, age and gender have an influence on the levels of rabies virus neutralizing antibody (RVNA) after ID rabies vaccination.

Materials and Methods

This is a retrospective study based on electronic health record vaccination data of Belgian military personnel who received ID rabies PrEP with a three injections regimen during the period 2014–2017. Serology was determined by using the RFFIT method. Fischer’s exacts tests were used to evaluate the effect of each independent variable on RVNA levels.

Results

In this study, 2,112 subjects were included. All but one seroconverted with a RVNA level ≥0.5 IU/mL. About 48% of subjects developed an antibody titer of >10 IU/mL, 36% had antibody levels 3–10 IU/mL and 16% had an antibody level 0.5–2.99 IU/mL. Statistically significant (p = 0.0018) higher RVNA levels are observed in the groups that received vaccination doses later as planned. Timing of serology determination also influenced RVNA levels significantly (p = 0.000). Antibody levels were significantly higher in females than in males (p = 0.000). Age did influence RVNA levels significantly (p = 0.022).

Conclusions

Timing of vaccine dose administration, timing of serology testing, sex and age do significantly influence the humoral B-cell response to ID administered rabies vaccine.
Discontinuation Rates of Antidepressant Use by Dutch Soldiers
Authors: Janssen Debbie G A , Vermetten Eric , Egberts Toine C G , Heerdink Eibert R
Published: April 2019

Introduction

Soldiers have a higher risk for developing psychiatric disorders that require treatment; often with antidepressants. However, antidepressants as well as the psychiatric disorder, may influence military readiness in several ways. In the general population, early discontinuation of antidepressant treatment is often seen. It is yet unknown whether this occurs to a similar extent in soldiers. The objective of this study was to evaluate discontinuation of antidepressant use by Dutch soldiers in the first 12 months after start and determinants thereof.

Materials and Methods

Data were obtained from the military pharmacy. All Dutch soldiers who started using an antidepressant between 2000 and 2014 were included. Kaplan–Meier curves were constructed to estimate the discontinuation rate over time and the influence of each determinant on discontinuation rate was estimated using Cox regression.

Results

About 25.9% of de 2479 starters had discontinued their antidepressant use after 1 month; after 3 and 6 months this number increased to 52.7% and 70.3%, respectively. Early discontinuation was higher in soldiers who received their first prescription from a neurologist or rehabilitation specialist (HR 1.85, 95% CI 1.55–2.21, HR 2.66 95% CI 1.97–3.58) compared to soldiers with a first prescription from a general practitioner. In addition, early discontinuation was lower in soldiers who were prescribed serotonin reuptake inhibitors and other antidepressants (HR 0.57, 95% CI 0.51–0.60, HR 0.63, 95% CI 0.55–0.73) and in soldiers between 40 and 50 years of age (HR 0.79, 95% CI 0.70–0.89).

Conclusion

More than half of the soldiers discontinued their prescribed antidepressant within 3 months and after 6 months, only 30% were still on antidepressants.
Prospective Memory in Service Members with Mild Traumatic Brain Injury
Authors: Settle Jill R , Clawson Deborah M , Sebrechts Marc M , French Louis M , Massey Watts Adreanna T , Duncan Connie C
Published: April 2019

Introduction

Prospective memory (PM) is the ability to remember the intention to perform an action in the future. Following mild traumatic brain injury (mTBI), the brain structures supporting such PM may be compromised. PM is essential for remembering activities specific to TBI survivors that promote recovery, such as following doctors’ orders, taking necessary medications, completing physical rehabilitation exercises, and maintaining supportive social relationships. Since the year 2000, more than 315,897 US Service Members are reported to have sustained an mTBI1, yet little has been done to address possible PM concerns. Therefore, identifying impaired PM and interventions that may ameliorate such deficits is important. The primary aim of this study was to determine whether task encoding using implementation intentions leads to better PM performance than encoding using rote rehearsal in Service Members with mTBI (n = 35) or with bodily injuries but no TBI (n = 8) at baseline and 6 months later.

Materials and Method

Participants were randomized to one of the two encoding conditions. They were asked to remember to complete a series of four tasks over the course of a 2-hour event-related potential session and to contact a staff member during a specified 2-hour window later that day. PM performance was assessed based on completion of each task at the appropriate time. IRB approval was obtained from The Catholic University of America, Walter Reed National Military Medical Center, and Ft. Belvoir Community Hospital.

Results

Service Members with mTBI using implementation intentions outperformed those using rote rehearsal. The effect of injury type and the interaction between encoding condition and injury type did not yield differences that were statistically significant.

Conclusions

The results suggest that implementation intentions may be a useful PM remediation strategy for those who have sustained mTBI. Future research should validate these findings in a larger sample
Cross-Sectional Study of Sexual Behavior, Alcohol Use, and Mental Health Conditions Associated With Sexually Transmitted Infections Among Deploying Shipboard US Military Personnel
Authors: Harbertson Judith , Scott Paul T , Lemus Hector , Michael Nelson L , Hale Braden R
Published: April 2019

Introduction

Limited comprehensive data exist on risk behavior associated with sexually transmitted infections (STI) among ship-assigned US military personnel during the predeployment time period (PDT). This study examined whether sexual risk behaviors, alcohol use, involuntary drug consumption (IDC), posttraumatic stress disorder (PTSD), and depression during the 12 months prior to deployment were associated with provider-diagnosed STIs in this population.

Materials and Methods

Using cross-sectional data collected during 2012–2014 among sexually active personnel, multivariable regression assessed factors associated with STIs among all men (n = 1,831). Stratified analyses were conducted among men who have sex with women (MSW, n = 1,530), men who have sex with men or men and women (MSM, n = 83), and excluded those not reporting sexual partner gender (n = 218).

Results

Among MSW, transactional sex (AOR 3.8, 95% CI 1.5–9.4) meeting sexual partners at work (AOR 4.3, 95% CI 2.0–9.2), IDC (AOR 6.6, 95% CI 3.0–14.5), and incomplete mental health assessments (AOR 4.4, 95% CI 1.6–12.0) were significantly associated with STIs after adjustment. Among all men, those who identified as MSM (AOR 4.6, 95% CI 1.9–11.2) and drug screen positive (AOR 3.3, 95% CI 1.3–8.6) were significantly more likely to report an STI.

Conclusions

Previously unreported factors significantly associated with STIs at the PDT among MSW in the adjusted analysis were meeting sexual partners at work and IDC. IDC during the PDT warrants further exploration. These results can inform tailored STI reduction interventions among shipboard personnel and similarly aged civilians undergoing similar transition/travel experiences.
Brazilian Jiu Jitsu Training for US Service Members and Veterans with Symptoms of PTSD
Authors: Willing Alison E , Girling Sue Ann , Deichert Ryan , Wood-Deichert Rebecca , Gonzalez Jason , Hernandez Diego , Foran Elspeth , Sanberg Paul R , Kip Kevin E
Published: April 2019

Introduction

The United States has been actively involved in major armed conflicts over the last 15 years. As a result, a significant proportion of active duty service personnel and returning veterans have endured combat, putting them at risk for developing post-traumatic stress disorder (PTSD), a disabling disorder that may occur after exposure to a traumatic event. Current therapies often require long-term, time-intensive and costly commitment from the patient and have variable degrees of success. There remains an ongoing need for better therapies, including complementary medicine approaches that can effectively reduce PTSD symptoms. While anecdotal evidence suggests that routine practice of Brazilian Jiu Jitsu (BJJ) can reduce symptoms of PTSD, there have been no formal studies to address this.

Materials and Methods

This study was approved by the University of South Florida Institutional Review Board (#PRO00019430). Male US active duty service members and veterans from the Tampa area participated in a 5-month (40 sessions) BJJ training program. Before beginning and again midway through and upon completion of training the participants completed several validated self-report measures that addressed symptoms of PTSD and other co-morbid conditions. Effect size and 95% confidence intervals were determined using a within-person single-group pretest–posttest design.

Results

Study participants demonstrated clinically meaningful improvements in their PTSD symptoms as well as decreased symptoms of major depressive disorder, generalized anxiety and decreased alcohol use; effect sizes varied from 0.80 to 1.85.

Conclusions

The results from this first-of-kind pilot study suggest that including BJJ as a complementary treatment to standard therapy for PTSD may be of value. It will be necessary to validate these promising results with a larger subject cohort and a more rigorous experimental design before routinely recommending this complementary therapy.
The Impact of Trust, Satisfaction, and Perceived Quality on Preference for Setting of Future Care Among Veterans With PTSD
Authors: Haro Elizabeth , Mader Michael , Noël Polly H , Garcia Hector , Vogt Dawne , Bernardy Nancy , Bollinger Mary , Pugh Mary Jo V , Finley Erin P
Published: April 2019

Introduction

Among US veterans, posttraumatic stress disorder (PTSD) is a high-prevalence condition; more than a million veterans of all combat eras are service-connected for this condition. Research on factors driving veterans’ decision-making regarding preferred setting for PTSD care has been limited. The purpose of this study was to understand factors associated with preferences for setting of future PTSD care among veterans service-connected for PTSD.

Materials and Methods

We conducted a cross-sectional mailed survey among veterans with service connection for PTSD in Texas and Vermont identified from the Veterans Services Network Corporate Mini Master File (VETSNET). Survey items were intended to elucidate PTSD healthcare decision-making and queried utilization, perceived need for care, and satisfaction and preferences for VA, community, and/or military setting for receipt of future PTSD care. Logistic regression was used to identify factors associated with preference for care setting. UT Health San Antonio’s Institutional Review Board determined this quality improvement project to be non-research.

Results

Veterans (n = 2,327) were surveyed with an overall response rate of 37.1%. Most veterans (72.4%) identified VA as a preferred site for their future PTSD care; a substantial, but smaller, number of veterans identified being interested in receiving care in community (39.9%) and military (12.7%) settings. Factors associated with preferences for future care setting included demographics (e.g., ethnicity, income), availability of healthcare coverage, prior experiences of care, and attitudes related to perceived quality of care and trust in VA.

Conclusions

These findings suggest that it is important to retain foundational mental health services within VA, as well as to continue to invest in building provider and network capacity in community settings, to ensure alignment with veteran preferences for care setting.
Validity of Digital and Manual Refractometers for Measuring Urine Specific Gravity During Field Operations: A Brief Report
Authors: Heileson Jeffery L , Jayne Julianna M
Published: April 2019

Introduction

Dehydration can have an immediate negative impact on the performance of Soldiers in training or combat environments. Field expedient methods for assessing hydration status may be valuable for service members. Measurement of urine-specific gravity (USG) via refractometer is inexpensive, simple, fast, and a validated indicator of hydration status. Manual (MAN) and digital (DIG) refractometers are commonly used in laboratory settings however, digital (DIG) devices have not been validated in the field against MAN devices. The purpose of this study was to determine the validity and feasibility of using a DIG refractometer to assess USG compared to a MAN refractometer during a military field training exercise.

Materials and Methods

Fifty-six military service members provided 672 urine samples during two 10-day field training exercises in central Texas. USG was assessed using a MAN and a DIG refractometer with cutoff value of ≥1.020 indicating hypohydration. The study received a non-human research determination.

Results

The MAN measurements were strongly correlated with the DIG (r = 0.91, p < 0.0001) measurements. Bland-Altman analysis demonstrated agreement between the refractometers. The DIG displayed good sensitivity (93.9%) and specificity (85.8%) compared to the MAN.

Conclusion

The DIG refractometer used in this study was reliable and valid compared with a MAN device and was feasible for use in a field environment; however, the DIG refractometer tended to over overestimate hypohydration.
Missile Injury of the Sciatic Nerve: Observational Study Supporting Early Exploration and Direct Suture With Flexed Knee
Authors: Mathieu Laurent , Pfister Georges , Murison James Charles , Oberlin Christophe , Belkheyar Zoubir
Published: April 2019

Missile injuries of the sciatic nerve are frequently encountered in modern violent conflicts. Gunshot and fragment wounds may cause large nerve defects, for which management is challenging. The great size of the sciatic nerve, in both diameter and length, explains the poor results of nerve repair using autografts or allografts. To address this issue, we used a simple technique consisting of a direct suture of the sciatic nerve combined with knee flexion for 6 weeks. Despite a published series showing that this procedure gives better results than sciatic nerve grafting, it remains unknown or underutilized. The purpose of this cases study is to highlight the efficiency of direct sciatic nerve coaptation with knee flexed through three cases with missile injuries at various levels. At the follow-up of two years, all patients were pain free with a protective sensory in the sole and M3+ or M4 gastrocnemius muscles, regardless of the injury level. Recovery was also satisfying in the fibular portion, except for the very proximal lesion. No significant knee stiffness was noticed, including in a case suffering from an associated distal femur fracture. Key points to enhance functional recovery are early nerve repair (as soon as definitive bone fixation and stable soft-tissue coverage are achieved) and careful patient selection.
Shared Signature Dynamics Tempered by Local Fluctuations Enables Fold Adaptability and Specificity
Authors: Zhang She , Li Hongchun , Krieger James M , Bahar Ivet
Published: April 2019

Recent studies have drawn attention to the evolution of protein dynamics, in addition to sequence and structure, based on the premise structure-encodes-dynamics-encodes-function. Of interest is to understand how functional differentiation is accomplished while maintaining the fold, or how intrinsic dynamics plays out in the evolution of structural variations and functional specificity. We performed a systematic computational analysis of 26,899 proteins belonging to 116 CATH superfamilies. Characterizing cooperative mechanisms and convergent/divergent features that underlie the shared/differentiated dynamics of family members required a methodology that lends itself to efficient analyses of large ensembles of proteins. We therefore introduced, SignDy, an integrated pipeline for evaluating the signature dynamics of families based on elastic network models. Our analysis confirmed that family members share conserved, highly cooperative (global) modes of motion. Importantly, our analysis discloses a subset of motions that sharply distinguishes subfamilies, which lie in a low-to-intermediate frequency regime of the mode spectrum. This regime has maximal impact on functional differentiation of families into subfamilies, while being evolutionarily conserved among subfamily members. Notably, the high-frequency end of the spectrum also reveals evolutionary conserved features across and within subfamilies; but in sharp contrast to global motions, high-frequency modes are minimally collective. Modulation of robust/conserved global dynamics by low-to-intermediate frequency fluctuations thus emerges as a versatile mechanism ensuring the adaptability of selected folds and the specificity of their subfamilies. SignDy further allows for dynamics-based categorization as a new layer of information relevant to distinctive mechanisms of action of subfamilies, beyond sequence or structural classifications.
Aneuploidy Enables Cross-Adaptation to Unrelated Drugs
Authors: Yang Feng , Teoh Flora , Tan Alrina Shin Min , Cao Yongbing , Pavelka Norman , Berman Judith
Published: April 2019

Aneuploidy is common both in tumor cells responding to chemotherapeutic agents and in fungal cells adapting to antifungal drugs. Because aneuploidy simultaneously affects many genes, it has the potential to confer multiple phenotypes to the same cells. Here, we analyzed the mechanisms by which Candida albicans, the most prevalent human fungal pathogen, acquires the ability to survive both chemotherapeutic agents and antifungal drugs. Strikingly, adaptation to both types of drugs was accompanied by the acquisition of specific whole-chromosome aneuploidies, with some aneuploid karyotypes recovered independently and repeatedly from very different drug conditions. Specifically, strains selected for survival in hydroxyurea, an anticancer drug, acquired cross-adaptation to caspofungin, a first-line antifungal drug, and both acquired traits were attributable to trisomy of the same chromosome: loss of trisomy was accompanied by loss of adaptation to both drugs. Mechanistically, aneuploidy simultaneously altered the copy number of most genes on chromosome 2, yet survival in hydroxyurea or caspofungin required different genes and stress response pathways. Similarly, chromosome 5 monosomy conferred increased tolerance to both fluconazole and to caspofungin, antifungals with different mechanisms of action. Thus, the potential for cross-adaptation is not a feature of aneuploidy per se; rather, it is dependent on specific genes harbored on given aneuploid chromosomes. Furthermore, pre-exposure to hydroxyurea increased the frequency of appearance of caspofungin survivors, and hydroxyurea-adapted C. albicans cells were refractory to antifungal drug treatment in a mouse model of systemic candidiasis. This highlights the potential clinical consequences for the management of cancer chemotherapy patients at risk of fungal infections.
DNA sequence influences hexasome orientation to regulate DNA accessibility
Authors: Brehove Matthew , Shatoff Elan , Donovan Benjamin T , Jipa Caroline M , Bundschuh Ralf , Poirier Michael G
Published: April 2019

Nucleosomes, the fundamental organizing units of eukaryotic genomes, contain ∼146 base pairs of DNA wrapped around a histone H3–H4 tetramer and two histone H2A–H2B dimers. Converting nucleosomes into hexasomes by removal of a H2A–H2B dimer is an important regulatory event, but its regulation and functional consequences are not well-understood. To investigate the influence of hexasomes on DNA accessibility, we used the property of the Widom-601 Nucleosome Positioning Sequence (NPS) to form homogeneously oriented hexasomes in vitro. We find that DNA accessibility to transcription factors (TF) on the hexasome H2A–H2B distal side is identical to naked DNA, while the accessibility on the H2A–H2B proximal side is reduced by 2-fold, which is due to a 2-fold reduction in hexasome unwrapping probability. We then determined that a 23 bp region of the Widom-601 NPS is responsible for forming homogeneously oriented hexasomes. Analysis of published ChIP-exo data of hexasome containing genes identified two DNA sequence motifs that correlate with hexasome orientation in vivo, while ExoIII mapping studies of these sequences revealed they generate homogeneously oriented hexasomes in vitro. These results indicate that hexasome orientation, which is influenced by the underlying DNA sequence in vivo, is important for modulating DNA accessibility to regulate transcription.
Tsr4 and Nap1, two novel members of the ribosomal protein chaperOME
Authors: Rössler Ingrid , Embacher Julia , Pillet Benjamin , Murat Guillaume , Liesinger Laura , Hafner Jutta , Unterluggauer Julia Judith , Birner-Gruenberger Ruth , Kressler Dieter , Pertschy Brigitte
Published: April 2019

Dedicated chaperones protect newly synthesized ribosomal proteins (r-proteins) from aggregation and accompany them on their way to assembly into nascent ribosomes. Currently, only nine of the ∼80 eukaryotic r-proteins are known to be guarded by such chaperones. In search of new dedicated r-protein chaperones, we performed a tandem-affinity purification based screen and looked for factors co-enriched with individual small subunit r-proteins. We report the identification of Nap1 and Tsr4 as direct binding partners of Rps6 and Rps2, respectively. Both factors promote the solubility of their r-protein clients in vitro. While Tsr4 is specific for Rps2, Nap1 has several interaction partners including Rps6 and two other r-proteins. Tsr4 binds co-translationally to the essential, eukaryote-specific N-terminal extension of Rps2, whereas Nap1 interacts with a large, mostly eukaryote-specific binding surface of Rps6. Mutation of the essential Tsr4 and deletion of the non-essential Nap1 both enhance the 40S synthesis defects of the corresponding r-protein mutants. Our findings highlight that the acquisition of eukaryote-specific domains in r-proteins was accompanied by the co-evolution of proteins specialized to protect these domains and emphasize the critical role of r-protein chaperones for the synthesis of eukaryotic ribosomes.
MethylCal: Bayesian calibration of methylation levels
Authors: Ochoa Eguzkine , Zuber Verena , Fernandez-Jimenez Nora , Bilbao Jose Ramon , Clark Graeme R , Maher Eamonn R , Bottolo Leonardo
Published: April 2019

Bisulfite amplicon sequencing has become the primary choice for single-base methylation quantification of multiple targets in parallel. The main limitation of this technology is a preferential amplification of an allele and strand in the PCR due to methylation state. This effect, known as ‘PCR bias', causes inaccurate estimation of the methylation levels and calibration methods based on standard controls have been proposed to correct for it. Here, we present a Bayesian calibration tool, MethylCal, which can analyse jointly all CpGs within a CpG island (CGI) or a Differentially Methylated Region (DMR), avoiding ‘one-at-a-time' CpG calibration. This enables more precise modeling of the methylation levels observed in the standard controls. It also provides accurate predictions of the methylation levels not considered in the controlled experiment, a feature that is paramount in the derivation of the corrected methylation degree. We tested the proposed method on eight independent assays (two CpG islands and six imprinting DMRs) and demonstrated its benefits, including the ability to detect outliers. We also evaluated MethylCal’s calibration in two practical cases, a clinical diagnostic test on 18 patients potentially affected by Beckwith–Wiedemann syndrome, and 17 individuals with celiac disease. The calibration of the methylation levels obtained by MethylCal allows a clearer identification of patients undergoing loss or gain of methylation in borderline cases and could influence further clinical or treatment decisions.
Predisposition of Wingless Subgroup Medulloblastoma for Primary Tumor Hemorrhage
Authors: Reisinger Dominik , Gojo Johannes , Kasprian Gregor , Haberler Christine , Peyrl Andreas , Azizi Amedeo A , Mayr Lisa , Chocholous Monika , Kool Marcel , Czech Thomas , Slavc Irene
Published: April 2019

BACKGROUND

Primary intratumoral hemorrhage as a presenting sign is rare in children with medulloblastomas but may result in severe complications. Given the distinct properties of molecular medulloblastoma subgroups, the impact on neurosurgical practice has still to be defined.

OBJECTIVE

To investigate both clinical and radiological presentation of intratumoral hemorrhage in medulloblastoma patients in the context of molecular subgroups.

METHODS

Data of all consecutive medulloblastoma patients treated at our institution between 1993 and 2018 (n = 104) were retrospectively reviewed in respect of clinical and radiological presentation as well as molecular subgroups. For cases with available tumor tissue (n = 86), subgroups were assigned by either 450 K methylation array or immunohistochemistry and CTNNB1 sequencing. Available imaging at diagnosis (n = 62) was reviewed by an experienced neuroradiologist.

RESULTS

Within the entire cohort, 4 patients (4%) presented with massive spontaneous hemorrhage. Although no patient died as a direct consequence of hemorrhage, all suffered from serious sequelae. Moreover, 3 additional patients displayed radiological evidence of significant hemorrhage. Interestingly, all 7 cases belonged to the wingless (WNT) subgroup (n = 13), resulting in intratumoral hemorrhage in 54% (7/13) of pediatric WNT medulloblastomas. In contrast, significant hemorrhage was absent in all other molecular subgroups.

CONCLUSION

Our results suggest that a substantial proportion of pediatric WNT medulloblastomas display significant intratumoral hemorrhage at the time of diagnosis. Consequently, the presence of significant hemorrhage in fourth ventricle childhood tumors is suggestive of WNT medulloblastoma and should lead to a less aggressive attempt for total resection in this prognostically favorable tumor type.
Role of plant protein in nutrition, wellness, and health
Authors: Ahnen Rylee T , Jonnalagadda Satya S , Slavin Joanne L
Published: April 2019

Plant-based diets, and more specifically plant-based proteins, have been the subject of growing interest from researchers and consumers because of their potential health benefits as well as their positive environmental impact. Of course, plant proteins are found in plant foods, and positive health benefits of plant foods are linked to dietary fiber, vitamins, minerals, and phytochemicals. In epidemiological studies it is not possible to separate out the health benefits of plant foods in general as opposed to plant proteins specifically. Additionally, few vegans, who consume only plant-based proteins, are included in existing prospective cohort studies. Isolated plant proteins (soy, pea) have been used in intervention trials, but often to improve biomarkers linked to disease risk, including serum lipids or blood pressure. This review is an overview of plant proteins, the whole foods they are associated with, and the potential health benefits linked to consumption of protein from plant sources. Plant proteins and their potential for reducing the risk of developing metabolic syndrome, diabetes management, cancer prevention, and weight management are each discussed, as are the various rating systems currently used to determine protein quality from plant sources. Although additional research is needed that focuses specifically on the role that plant protein plays in the prevention and management of these chronic illnesses, rather than the role played by a more general plant-based diet, evidence suggests that plant proteins offer nutritional benefits to those who consume them. Limitations to plant proteins, including lower protein quality, must also be considered in this discussion.
Using Machine Learning and the Electronic Health Record to Predict Complicated Clostridium difficile Infection
Authors: Li Benjamin Y , Oh Jeeheh , Young Vincent B , Rao Krishna , Wiens Jenna
Published: April 2019

Background

Clostridium (Clostridioides) difficile infection (CDI) is a health care–associated infection that can lead to serious complications. Potential complications include intensive care unit (ICU) admission, development of toxic megacolon, need for colectomy, and death. However, identifying the patients most likely to develop complicated CDI is challenging. To this end, we explored the utility of a machine learning (ML) approach for patient risk stratification for complications using electronic health record (EHR) data.

Methods

We considered adult patients diagnosed with CDI between October 2010 and January 2013 at the University of Michigan hospitals. Cases were labeled complicated if the infection resulted in ICU admission, colectomy, or 30-day mortality. Leveraging EHR data, we trained a model to predict subsequent complications on each of the 3 days after diagnosis. We compared our EHR-based model to one based on a small set of manually curated features. We evaluated model performance using a held-out data set in terms of the area under the receiver operating characteristic curve (AUROC).

Results

Of 1118 cases of CDI, 8% became complicated. On the day of diagnosis, the model achieved an AUROC of 0.69 (95% confidence interval [CI], 0.55–0.83). Using data extracted 2 days after CDI diagnosis, performance increased (AUROC, 0.90; 95% CI, 0.83–0.95), outperforming a model based on a curated set of features (AUROC, 0.84; 95% CI, 0.75–0.91).

Conclusions

Using EHR data, we can accurately stratify CDI cases according to their risk of developing complications. Such an approach could be used to guide future clinical studies investigating interventions that could prevent or mitigate complicated CDI.
Measuring inequality
Authors: McGregor Thomas , Smith Brock , Wills Samuel
Published: April 2019

Inequality is important, both for its own sake and for its political, social, and economic implications. However, measuring inequality is not straightforward, as it requires decisions to be made on the variable, population, and distributional characteristics of interest. These decisions will naturally influence the conclusions that are drawn so they must be closely linked to an underlying purpose, which is ultimately defined by a social welfare function. This paper outlines important considerations when making each of these decisions, before surveying recent advances in measuring inequality and suggesting avenues for future work.
Progressive Multicomponent Intervention for Older Adults in Home Health Settings Following Acute Hospitalization: Randomized Clinical Trial Protocol
Authors: Falvey Jason R , Mangione Kathleen K , Nordon-Craft Amy , Cumbler Ethan , Burrows Kristine L , Forster Jeri E , Stevens-Lapsley Jennifer E
Published: April 2019

Background

Hospitalization is a profound contributor to functional loss for older adults. Many modifiable risk factors (ie, weakness) may persist after hospitalization, representing portents of poor health, re-hospitalization, or death. Older adults frequently receive home health (HH) care after hospitalization to manage functional deficits that have worsened during hospital stays. However, how best to manage these deficits in HH settings has yet to be determined.

Objective

The objective is to determine if a higher intensity, progressive, multi-component (PMC) intervention, initiated upon admission to HH after an acute hospitalization, improves objectively measured and self-reported physical function more than usual care (UC) physical therapy.

Design

This will be a 2-arm randomized controlled clinical trial.

Setting

The setting will be participant homes.

Participants

A total of 200 older adults with deconditioning following acute hospitalization and referred for HH physical therapy will participate.

Intervention

Participants will be randomized to either a PMC treatment group or a UC group and receive 12 therapy visits over a 60-day period. PMC participants will perform lower extremity resistance training at 80% of a 1-repetition maximum, task-specific activities of daily living training, along with advanced gait and balance training. PMC groups will also receive nutritional supplementation and nursing support during transition from hospital to home. The UC group will receive standard of care HH interventions.

Measurements

Physical performance, self-reported function, fatigue, and health care utilization outcomes will be measured at baseline, 30 days, 60 days, 90 days, and 180 days. All measures will be assessed by blinded study personnel.

Limitations

The limitation is an inability to blind treating therapists to study allocation.

Conclusions

The authors hope to determine whether higher intensity, multi-component exercise interventions improve outcomes more than UC physical therapy for older adults recovering from acute hospitalization in HH settings.
SURVEY OF INDOOR RADON LEVELS IN SOME UNIVERSITIES IN SOUTH WESTERN NIGERIA
Authors: Ajayi Oladele Samuel , Owoola Eunice Oluwabunmi , Olubi Omodele Emmanuel , Dike Chidiebere Goodluck
Published: April 2019

Indoor radon investigation was carried out in offices of three university campuses located in South-Western part of Nigeria; Federal University of Technology Akure (FUTA), Ekiti State University (EKSU) and Federal University Oye-Ekiti (FUOYE) using CR39 detectors. The mean activity concentration of indoor radon for the investigated offices of all three university campuses was estimated to be 222 ± 44 Bq m−3, which was below the reference level of 300 Bq m−3 recommended by the International Commission on Radiological Protection (ICRP 115). For the three institutions, the probability of lung cancer induction at age 70 years with respect to age of exposure (40, 50, and 60 years) ranged between 1.06 × 10−7 and 6.24 × 10−5. The expected mortality rate due to exposure to a radon activity concentration ranging from 7 to 1358 Bq m−3 was estimated to range from 0 to 44 deaths among a population of 10,000 persons.
Prevalence and incidence of narcolepsy in a US health care claims database, 2008–2010
Authors: Scheer Darren , Schwartz Skai W , Parr Maria , Zgibor Janice , Sanchez-Anguiano Aurora , Rajaram Lakshminarayan
Published: April 2019

Study Objectives

To determine the prevalence and incidence of narcolepsy using a large US health care claims database.

Methods

The Truven Health MarketScan Commercial Dissertation Database (THMCDD) was used to estimate prevalence and incidence of narcolepsy, with and without cataplexy, by age groups, gender, and region among patients under age 66 years with continuous enrollment for years 2008–2010. THMCDD contains health claims information for more than 18 million people. Prevalence was expressed as cases/100 000 persons. Average annual incidence (using varying criteria for latency between the diagnostic tests, polysomnograph coupled with multiple sleep latency test [MSLT], and the diagnosis) was expressed as new cases/100 000 persons/year.

Results

There were 8 444 517 continuously enrolled patients and 6703 diagnosed with narcolepsy (prevalence overall: 79.4/100 000; without cataplexy: 65.4/100 000; with cataplexy: 14.0/100 000). On the basis of the three definitions of incidence, overall average annual incidence was 7.67, 7.13, and 4.87/100 000 persons/year. Incidence for narcolepsy without cataplexy was generally several times higher than narcolepsy with cataplexy. Prevalence and incidence were approximately 50% greater for females compared to males across most age groups. Prevalence was highest among the 21–30 years age group, with incidence highest among enrollees in their early 20s and late teens. Regionally, the North Central United States had the highest prevalence and incidence, whereas the West was the lowest.

Conclusion

We found greater prevalence and incidence of narcolepsy (including without cataplexy) than most previous studies. The increased proportions in females, enrollees in their early 20s, and US regional differences require further study. Increased awareness and early identification is critical in the management of this burdensome condition.
Auto positive airway pressure therapy reduces pulmonary pressures in adults admitted for acute heart failure with pulmonary hypertension and obstructive sleep apnea. The ASAP-HF Pilot Trial
Authors: Sharma Sunil , Fox Henrik , Aguilar Francisco , Mukhtar Umer , Willes Leslee , Bozorgnia Benham , Bitter Thomas , Oldenburg Olaf
Published: April 2019

Objectives

Pulmonary hypertension (PH) is extremely common in acute decompensated heart failure (ADHF) patients and predicts increased mortality. Obstructive sleep apnea (OSA), highly prevalent in congestive heart failure patients, may contribute to further elevated pulmonary pressures. This study evaluates the impact of positive airway pressure (PAP) therapy on PH in patients admitted for ADHF with OSA.

Methods

A two-center randomized control trial comparing standard of care (SOC) therapy for ADHF versus addition of PAP therapy in patients with concomitant OSA.

Results

Twenty-one consecutive patients were enrolled with 1:1 randomization to SOC versus SOC plus 48-hour PAP therapy protocol. In the intervention arm, the mean pulmonary artery systolic pressure (PASP) difference before therapy and after 48 hours of PAP therapy was −15.8 ± 3.2 (58.6 ± 2.5 mm Hg to 42.8 ± 2.7) versus the SOC arm where the mean PASP difference was −5.2 ± 2.6 (62.7 ± 3.3 mm Hg reduced to 57.5 ± 3.9) (p = 0.025). In addition, ejection fraction in the intervention arm improved (3.4 ± 1.5% versus −0.5 ± 0.5 %) (p = 0.01). Significant improvement was also noted in tricuspid annular plane systolic excursion (TAPSE) and right ventricular systolic area in the intervention arm but not in NT-pro-BNP or 6-minute walk distance.

Conclusions

In patients with ADHF and OSA, addition of 48 hours of PAP therapy to SOC treatment significantly reduced PH. In addition, PAP therapy was able to improve right and left ventricular function.

ClinicalTrials.gov identifier: NCT02963597.
Calciphylaxis: Diagnosis, Pathogenesis, and Treatment
Authors: Chang John J.
Published: April 2019

Calciphylaxis is a cutaneous ischemic infarct caused by total occlusion of blood vessels initiated by vascular calcification. Until recently, treatments have been limited to controlling its risk factors and optimizing wound care. However, recent advances in clinical understanding of the mechanism of calciphylaxis have identified promising potential therapeutic targets. This article is a narrative review summarizing the clinical features, diagnosis, pathogenesis, and treatment of calciphylaxis.

GENERAL PURPOSE

To provide information on the pathogenesis, clinical features, diagnosis, and treatment of calciphylaxis.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:

1. Recognize the pathogenesis and clinical features of and risk factors for calciphylaxis.

2. Explain the diagnosis and management of a patient with calciphylaxis.
Professionals’ Knowledge, Attitudes, and Practices Related to Pressure Injuries in Canada
Authors: LeBlanc Kimberly , Woo Kevin , Bassett Katie , Botros Mariam
Published: April 2019

BACKGROUND:

Pressure injuries (PIs) represent a significant burden on the healthcare system and have a negative impact on the quality of life of those affected by these wounds. Despite best practice guidelines and other protocols to help healthcare facilities prevent PIs, the prevalence of PIs in Canada across all healthcare settings is concerning.

OBJECTIVE:

To describe the pattern of PI prevention and identify national priorities and opportunities to address PIs.

METHODS:

A descriptive, cross-sectional, online survey was created between August and December 2017 to explore Canadian healthcare professionals’ knowledge, attitudes, and practices related to PIs.

RESULTS:

In total, 590 surveys were completed. Eighty-five percent of respondents confirmed that PIs occur in their work environments, and 29% claimed PIs are a frequent occurrence. Most of the respondents (91%) confirmed that they were part of a team that treats PIs. Of the 590 participants, 90% confirmed that they are aware of PI prevention devices and technologies. Between 80% and 90% attest to using offloading devices including prophylactic dressings to prevent PIs, but only 20% instituted measures to address moisture-associated skin damage.

CONCLUSIONS:

The findings from this survey have highlighted a disconnect between Canadian healthcare professionals’ awareness of PIs and the implementation of best practices for PI prevention. It is evident that, although the majority of respondents were aware of PIs and related treatment protocols, barriers still exist that impede optimized care and treatment.
A Histologic Perspective on Electrical and Thermal Burn-Injured Human Skin
Authors: Pielesz Anna , Gawłowski Andrzej , Biniaś Dorota , Bobiński Rafał , Kawecki Marek , Sama Ewa , Waksmańska Wioletta
Published: April 2019

OBJECTIVE:

To analyze specific spectroscopic (FT-Raman) and thermal (limiting oxygen index) aspects of skin samples exposed to electrical injury compared with thermal injury.

METHODS:

An observational case-control study was conducted at the Dr Stanislaw Sakiel Center for Burns Treatment in Siemianowice, Silesia, Poland. A scanning electron microscope was used to diagnose and illustrate the topography of skin samples from electrical and thermal burns and the morphologic effects on damaged versus undamaged skin surfaces. In particular, researchers attempted to detect spectroscopic and thermal changes at the molecular level, namely, specific biomarkers of tissue degeneration and their regeneration under the influence of the applied modifiers (antioxidants and orthosilicic acid solutions).

RESULTS:

Modification with l-ascorbic acid and hydrogel of orthosilicic acid caused an increase in the intensity of the amide I Raman peaks, whereas modification with sodium ascorbate and orthosilicic acid resulted in the separation of the band protein side chains (1,440–1,448 cm−1), which is a part of tissue regeneration. The best result was obtained when the skin was treated with 7% orthosilicic acid (limiting oxygen index, 26%).

CONCLUSIONS:

Antioxidant treatment may be advantageous in minimizing injury in patients with thermal burns but not always in electrical burns.
Where Do You Think You Are? A Grounded Theory Study of the Critical Factors Triggering the Existence and Fueling the Persistence of Incivility in Nursing
Authors: Samson-Mojares Roselle Ann , Chin Claudette R. , Colvin Mary K. , Umadhay Tony
Published: April 2019

BACKGROUND

Incivility in health care settings was first identified in 1976. The Institute of Medicine has called for a safer health care environment, and the Joint Commission emphasizes that disruptive behavior compromises patient safety. Incivility in nursing is a topic of interest, yet it had not been explored as a social process.

AIM

The purpose of this study was to acquire an understanding and develop a theory to address incivility in nursing.

METHOD

Twenty-nine RNs were interviewed based on Charmaz’s constructionist grounded theory.

RESULTS

Four categories emerged (neglecting, alienating, relinquishing, and finding oneself) that developed into the theory of self-positioning.

CONCLUSION

To understand incivility in nursing, one must, immersed within the institution, profession, and society, find and position the self. It is only then that we can address the health and well-being of RNs, provide quality care, and ensure patient safety.
Elevating diagnostic skills with logical reasoning
Authors: Gilliam Stephen
Published: April 2019

NPs can use the abductive, deductive, and inductive forms of reasoning to adopt a rational and consistent approach to transforming effective data into accurate diagnoses. A case example is used throughout the article to illustrate how these classic logical reasoning skills may be combined with knowledge and experience to address issues of diagnostic accuracy and decrease diagnostic errors.
Sharing clinical notes with patients
Authors: Adelman Deborah S. , Fant Catherine , Conner Debbie Nogueras
Published: April 2019

This article outlines a research project conducted to learn more about NPs' attitudes regarding sharing clinical notes with patients through a patient portal. Perceptions were positive overall. To achieve effective health outcomes, patient and family engagement is essential. Shared clinical notes provide an opportunity to achieve these goals.
Associations Between Physical Activity and Chronic Pain Severity in Youth With Chronic Abdominal Pain
Authors: Kichline Tiffany , Cushing Christopher C. , Ortega Adrian , Friesen Craig , Schurman Jennifer V.
Published: April 2019

Objectives:

The present study aimed to: (1) better understand physical activity levels in youth with chronic abdominal pain and (2) investigate the relationship between day-level physical activity related to next day pain intensity to identify any intraindividual heterogeneity.

Methods:

Seventy-one youth (M=13.34 y, SD=2.67 y) with chronic abdominal pain provided reports of pain severity and continuous objective reports of sedentary behavior, moderate-to-vigorous physical activity (MVPA), and total sleep time using accelerometers over 14 days.

Results:

Findings revealed that youth with chronic abdominal pain do not meet recommended levels of MVPA per day (M=34.64 min, SD=33.31 min). Further, results indicated a random effect of the previous day’s MVPA predicting pain severity. There was a small significant negative effect of within-person total sleep time as a predictor of pain severity.

Discussion:

The current study highlights the importance of separating between-person and within-person differences when examining the relationship between physical activity and pain severity. Future studies should explore moderating factors that may help to explain random effects to better understand the types of individuals with positive or negative relationships between physical activity and pain severity.