Confirmation of the Validity of the Relational Coordination Survey as a Measure of the Work Environment in a National Sample of Infection Preventionists

BACKGROUND

Health care-associated infections (HAIs) are leading causes of morbidity and mortality. Prevention of HAIs requires multifaceted approaches that consider the work environment in which interventions are implemented.

PURPOSE

This study assessed the construct validity of the Relational Coordination Survey (RCS) as a measure of the work environment in infection prevention departments.

METHODS

Data were obtained from 614 infection preventionists (IPs). Factor analysis and structural equation modeling tested the hypothesized model.

RESULTS

Cronbach's alpha for the 28-item RCS was .91. Factor analyses confirmed a four-factor solution that explained 58.17% of the variance. The fit indices for the model indicated an adequate fit, χ²(346) = 699.38, p < .00; comparative fit index = .94; root mean square error of approximation = .06.

CONCLUSIONS

The RCS may be a useful tool for measuring aspects of the work environment for IPs.

Increased Susceptibility to Aphids of Flowering Wheat Plants Exposed to Low Temperatures

Frost is known to directly affect flowering wheat plants (Triticum aestivum L.) and lead to reduced grain yield. Additionally, it may increase wheat susceptibility to economically important pests, such as aphids (Hemiptera: Aphididae). Wheat plants at flowering stage were exposed to one of the three temperature treatments: ambient (11-12°C), 0°C, and -3°C for 60 min. Preference (3-choice) and performance (no-choice) bioassays with aphids (Rhopalosiphum padi L.) were conducted 1, 3, 6, and 12 d after temperature treatments to assess effects of temperature-induced stress over time. As an initial feasibility study of using remote sensing technologies to detect frost-induced stress in flowering wheat plants, hyperspectral imaging data were acquired from wheat plants used in preference bioassays. Element analysis of wheat plants was included to determine the effect of temperature-induced stress on the nutritional composition of flowering wheat plants. The results from this study support the following cause-effect scenario: a 60-min exposure to low temperatures caused a significant decrease in potassium and copper content of wheat plants 6 d after temperature exposure, and it coincided with a marked increase in preference by aphids of wheat plants. The preference exhibited by aphids correlated positively with performance of aphids, so the preference-performance hypothesis was confirmed and possibly driven by potassium and copper content of wheat plants. In addition, we demonstrated that hyperspectral imaging data can be used to detect frost-induced susceptibility to aphid infestation in flowering wheat plants. These findings justify further research into airborne remote sensing of frost-induced stress and the possible secondary effects on crop susceptibility to arthropod pests.

How strict is galactose restriction in adults with galactosaemia? International practice

Dietary management of 418 adult patients with galactosaemia (from 39 centres/12 countries) was compared. All centres advised lactose restriction, 6 restricted galactose from galactosides ± fruits and vegetables and 12 offal. 38% (n=15) relaxed diet by: 1) allowing traces of lactose in manufactured foods (n=13) or 2) giving fruits, vegetables and galactosides (n=2). Only 15% (n=6) calculated dietary galactose. 32% of patients were lost to dietetic follow-up. In adult galactosaemia, there is limited diet relaxation.

Self-enforcing feedback activation between BCL6 and pre-B cell receptor signaling defines a distinct subtype of acute lymphoblastic leukemia

Studying 830 pre-B ALL cases from four clinical trials, we found that human ALL can be divided into two fundamentally distinct subtypes based on pre-BCR function. While absent in the majority of ALL cases, tonic pre-BCR signaling was found in 112 cases (13.5%). In these cases, tonic pre-BCR signaling induced activation of BCL6, which in turn increased pre-BCR signaling output at the transcriptional level. Interestingly, inhibition of pre-BCR-related tyrosine kinases reduced constitutive BCL6 expression and selectively killed patient-derived pre-BCR(+) ALL cells. These findings identify a genetically and phenotypically distinct subset of human ALL that critically depends on tonic pre-BCR signaling. In vivo treatment studies suggested that pre-BCR tyrosine kinase inhibitors are useful for the treatment of patients with pre-BCR(+) ALL.

Selective cardiac surveillance in patients with gynecologic cancer undergoing treatment with pegylated liposomal doxorubicin (PLD)

OBJECTIVE

The study objective was to examine the safety and cost savings of selective cardiac surveillance (CS) during treatment with pegylated liposomal doxorubicin (PLD).

METHODS

A retrospective, dual institution study of women receiving PLD for the treatment of a gynecologic malignancy was performed. The study period was 2002-2014. At both institutions, a selective strategy for CS was implemented in which only high-risk women with a cardiac history or with symptoms suggestive of cardiac toxicity during PLD treatment underwent a cardiac evaluation. Patient demographics, clinical and treatment history were evaluated. Cost analyses were performed utilizing professional/technical fee rates for echocardiogram and multi-gated acquisition scan for each state.

RESULTS

PLD was administered in 184 women. The mean patient age was 62.7years, and 79% were treated for recurrent ovarian or peritoneal carcinoma. The median cumulative administered dose of PLD was 300mg/m(2); 24 received >550mg/m(2). The median follow-up time was 20months. Of the 184 patients, the majority (n=157, 85.3%) did not undergo either an initial cardiac evaluation or surveillance during or post-PLD treatment. Fifty-three patients considered high risk for anthracycline-induced cardiotoxicity underwent CS. Only three patients (1.6%) in the entire cohort developed CHF that was possibly related to PLD treatment; all had significant pre-existing cardiac risk factors. Selective instead of routine use of CS in the study population resulted in a cost savings of $182,552.28.

CONCLUSION

Utilizing cardiac surveillance in select women undergoing PLD treatment for gynecologic malignancies resulted in significant health care cost savings without adversely impacting clinical outcomes.

Whole-exome sequencing points to considerable genetic heterogeneity of cerebral palsy

Cerebral palsy (CP) is a common, clinically heterogeneous group of disorders affecting movement and posture. Its prevalence has changed little in 50 years and the causes remain largely unknown. The genetic contribution to CP causation has been predicted to be ~2%. We performed whole-exome sequencing of 183 cases with CP including both parents (98 cases) or one parent (67 cases) and 18 singleton cases (no parental DNA). We identified and validated 61 de novo protein-altering variants in 43 out of 98 (44%) case-parent trios. Initial prioritization of variants for causality was by mutation type, whether they were known or predicted to be deleterious and whether they occurred in known disease genes whose clinical spectrum overlaps CP. Further, prioritization used two multidimensional frameworks-the Residual Variation Intolerance Score and the Combined Annotation-dependent Depletion score. Ten de novo mutations in three previously identified disease genes (TUBA1A (n=2), SCN8A (n=1) and KDM5C (n=1)) and in six novel candidate CP genes (AGAP1, JHDM1D, MAST1, NAA35, RFX2 and WIPI2) were predicted to be potentially pathogenic for CP. In addition, we identified four predicted pathogenic, hemizygous variants on chromosome X in two known disease genes, L1CAM and PAK3, and in two novel candidate CP genes, CD99L2 and TENM1. In total, 14% of CP cases, by strict criteria, had a potentially disease-causing gene variant. Half were in novel genes. The genetic heterogeneity highlights the complexity of the genetic contribution to CP. Function and pathway studies are required to establish the causative role of these putative pathogenic CP genes.

A two-step fluorinase enzyme mediated 18F labelling of an RGD peptide for positron emission tomography

Fluorine-18 radiolabelling of a peptide is conducted in water (pH 7.8 and 37 °C) using the fluorinase enzyme and a ‘click’ reaction.

Greater fear of hypoglycaemia with premixed insulin than with basal-bolus insulin glargine and glulisine: patient-reported outcomes from a 60-week randomised study

AIM

To assess the effect of initiating insulin treatment on quality of life of patients with type 2 diabetes (T2DM) in the 60-week All-to-Target trial (NCT00384085).

METHODS

Patient-reported outcomes from a phase IV, multicentre, randomised, open-label, parallel-group study were analysed. Participants were randomised to: insulin glargine with up to one insulin glulisine injection (G + 1); insulin glargine with stepwise addition of up to three insulin glulisine injections (G + 3); or twice-daily premixed 70/30 insulin protamine-aspart/aspart (PM-2). Patient-reported outcome questionnaires were administered at weeks 0, 6, 12, 24, 36, 48 and 60.

RESULTS

There were no between-group differences in the Psychosocial Adjustment to Illness State-Self Report (PAIS-SR) or in the EuroQoL Group Five-Dimension Self-Report Index Questionnaire (EQ-5D) from baseline to week 60; however, PAIS-SR scores improved significantly over this period in the G + 3 group (p = 0.0016) and EQ-5D scores worsened significantly in the PM-2 group (p = 0.02). Hypoglycemia Fear Survey Behaviour and Worry subscales worsened significantly for all groups, with greater deterioration being observed in the PM-2 group than in the G + 1 group (Behaviour, p = 0.0050; Worry, p = 0.0017) and G + 3 groups (Behaviour, p = 0.0105; Worry, p = 0.0016). Total scores on the Diabetes Quality of Life (DQoL) questionnaire improved more in the G + 3 group than in the PM-2 group over the study period (p = 0.0284), with all groups showing a significant improvement in DQoL score over time.

CONCLUSION

Insulin glargine-based regimens showed advantages over premixed insulin in a number of patient-reported outcome measures. The potential impact on fear of hypoglycaemia may be of particular relevance when addressing the major barriers to early insulin treatment.

166Ho and 90Y labeled 6D2 monoclonal antibody for targeted radiotherapy of melanoma: comparison with 188Re radiolabel

INTRODUCTION

An approach to radioimmunotherapy (RIT) of metastatic melanoma is the targeting of melanin pigment with monoclonal antibodies (mAbs) to melanin radiolabeled with therapeutic radionuclides. The proof of principle experiments were performed using a melanin-binding antibody 6D2 of IgM isotype radiolabeled with a β emitter (188)Re and demonstrated the inhibition of tumor growth. In this study we investigated the efficacy of 6D2 antibody radiolabeled with two other longer lived β emitters (90)Y and (166)Ho in treatment of experimental melanoma, with the objective to find a possible correlation between the efficacy and half-life of the radioisotopes which possess high energy β (E(max)>1.5 MeV) emission properties.

METHODS

6D2 was radiolabeled with longer lived β emitters (90)Y and (166)Ho in treatment of experimental melanoma in A2058 melanoma tumor-bearing nude mice. The immunoreactivity of the radiolabeled 6D2 mAb, its in vitro binding to the MNT1 human melanoma cells, the biodistribution and therapy in A2058 human melanoma bearing nude mice as well as dosimetry calculations were performed.

RESULTS

When labeled with the longer lived (90)Y radionuclide, the 6D2 mAb did not produce any therapeutic effect in tumor bearing mice while the reduction of the tumor growth by (166)Ho-6D2 was very similar to the previously reported therapy results for (188)Re-6D2. In addition, (166)Ho-labeled mAb produced the therapeutic effect on the tumor without any toxic effects while the administration of the (90)Y-labeled radioconjugate was toxic to mice with no appreciable anti-tumor effect.

CONCLUSIONS

(166)Ho-labeled mAb to melanin produced some therapeutic effect on the tumor without any toxic effects while the administration of the (90)Y-labeled radioconjugate was toxic to mice with no appreciable anti-tumor effect. We concluded that the serum half-life of the 6D2 carrier antibody matched well the physical half-life of (166)Ho to deliver the tumoricidal absorbed dose to the tumor. Further investigation of this radionuclide for RIT of melanoma is warranted.

Advance directives and HIV: a current trend in the inner city

Throughout the 1980's, HIV antiretroviral therapy was non-existent or insufficient, and patients admitted to hospitals were frequently terminal. In 1988 we evaluated the HIV related hospitalizations at the Lutheran Medical Center in Brooklyn, New York, and found that only 1.3 % of the patients had an advanced directive/living will. Fifty percent of the patients expired during their hospitalization. To assist health care professionals during this serious illness, medical decisions were needed from the patients and, at other times, from family members and/or significant others. Subsequently, patients were approached to discuss advance directives (AD). With the introduction of the Highly Active Antiretroviral Therapy, medical management has decreased HIV mortality. Patients may have started having different perceptions on the need for an AD. The study design was submitted to the Institutional Review Board (IRB), and the IRB granted a HIPPA waiver because this was a retrospective study which delinked the study data from any identification of the patient. The chart reviews were conducted to ascertain the existence of an AD for all patients admitted at the Lutheran Medical Center, Brooklyn, NY from 2004 to 2011. One hundred eighty-two patients were identified from their discharge codes for HIV or AIDS. The median age was 47 years (range 22-85 years). Median time since HIV diagnosis was 9.5 years (range 0-28 years). Ninety-two percent lacked an AD on admission. From the thirty patients that were older than 54 years of age, only four of them had an AD prior to admission. During hospitalization only 11 patients out of 187 enacted a new AD, which decreased the overall percentage of patients lacking an AD to 86.3 % (pre and during admission). The majority of HIV infected patients hospitalized lacked an AD. Our data did not indicate a greater predominance of ADs from a private practice or clinic setting. ADs did not increase with increasing age. Moreover, with longer years with an HIV diagnosis, the number of ADs did not increase. Our results would indicate that a different approach is necessary to adequately address ADs with this specific population, especially as their longevity increases.

Evaluation of Differences in Percentage of International Normalized Ratios in Range Between Pharmacist-Led and Physician-Led Anticoagulation Management Services

Background:

The safety and efficacy of warfarin depend on maintaining the international normalized ratio (INR) in an established range.

Objective:

The purpose was to determine whether a coordinated pharmacist-led approach improved percentage of INRs in therapeutic range in comparison to a physician-led anticoagulation management service (AMS).

Methods:

A retrospective chart review was conducted for patients at a multisite primary care organization. INR data for patients receiving warfarin management by a physician were collected from December 1, 2009 to May 31, 2010. These were compared to INR results from December 1, 2010 to May 31, 2011, during which patients received warfarin management from a pharmacist. The primary end points were percentage of INRs within a goal range of 2.0 to 3.0 and an expanded goal range of 1.8 to 3.2 for the physician-led group versus the pharmacist-led group.

Results:

The percentage of INR results within the goal range (2.0-3.0) was greater among patients in the pharmacist-led group (n = .130) than the physician-led group (n = 96; 57.5% vs 50.0%, respectively; P = .0004). The percentage of INR results <1.5 (7.3% vs 5.1%) and >3.5 (11.4% vs 7.1%) was also statistically significant in favor of the pharmacist-led AMS, with P values of .03 and .0004, respectively.

Conclusion:

A pharmacist-led AMS improved the percentage of INRs in range, with significantly less out-of-range results.

Predictors of self-injurious behaviour exhibited by individuals with autism spectrum disorder

BACKGROUND

Presence of an autism spectrum disorder is a risk factor for development of self-injurious behaviour (SIB) exhibited by individuals with developmental disorders. The most salient SIB risk factors historically studied within developmental disorders are level of intellectual disability, communication deficits and presence of specific genetic disorders. Recent SIB research has expanded the search for risk factors to include less commonly studied variables for people with developmental disorders: negative affect, hyperactivity and impulsivity.

METHOD

A heterogeneous sample of 617 individuals with autism spectrum disorder diagnoses was derived from the National Database of Autism Research. Latent constructs were estimated from items of the community version of the Aberrant Behaviour Checklist. Structural equation modelling was used to assess whether impulsivity, hyperactivity, negative affect, severity of stereotypy, intellectual functioning or severity of autism symptoms predicted severity of SIB.

RESULTS

Impulsivity (β = 0.46), followed by intellectual functioning (β = -0.39), and stereotypy (β = 0.23) were the variables most highly predictive of increased SIB; impulsivity and stereotypy remained significant predictors of SIB after severity of autism symptoms and intelligence quotient (IQ) were controlled for.

CONCLUSIONS

High levels of impulsivity and stereotypy were significant predictors of SIB in a large and diverse sample of people with confirmed autism diagnoses. Future research is needed on the effects of reducing impulsivity and stereotypy on the outcomes of treatment, early intervention and attempts to prevent the development of SIB.

Dosimetric consideration of transient volume enlargement induced by edema in prostate brachytherapy seed implants

PURPOSE

To investigate enlargement of prostate volume by edema during brachytherapy seed implantation and develop a nomogram model to calculate air-kerma strength (AKS) required for implantation of the enlarged transient prostatic volume.

MATERIALS AND METHODS

The prostate volume was measured prior and after seed implantation using trans-rectal ultrasound imaging in the operating room to obtain volume enlargement. A nomogram model was developed that calculates AKS required for implantation of the enlarged transient prostate volume with optimal dose coverage.

RESULTS

The measured prostate enlargement in this study was up to 60% of the initial volume. The effective prostatic volume enlargement was calculated for three isotopes: 125I, 103Pd and 131Cs. The effective volume enlargement for 125I implants was relatively small (< 10%) because of its long half-life. For 103Pd and 131Cs with short half-lives, additional AKS up to 20% and 30%, respectively, might be required to provide appropriate dose coverage of possible enlarged prostatic volumes.

CONCLUSIONS

Prostate volume enlargement should be considered to obtain optimal dose coverage particularly for short half-life isotopes such as 131Cs and 103Pd. The nomogram model developed in this work provides the AKS required for implants with a wide range of prostatic volume enlargements (5-100%) for three isotopes.

KEYWORDS

prostate brachytherapy; nomogram; air-kerma strength; edema; volume enlargement.