Characteristics Associated with Treatment Response and Satisfaction in Women Undergoing OnabotulinumtoxinA and Sacral Neuromodulation for Refractory Urgency Urinary Incontinence

PURPOSE

We sought to identify clinical and demographic characteristics associated with treatment response and satisfaction in women undergoing onabotulinumtoxinA and sacral neuromodulation therapies.

MATERIALS AND METHODS

We analyzed data from the ROSETTA (Refractory Overactive Bladder: Sacral NEuromodulation versus BoTulinum Toxin Assessment) trial. Baseline participant characteristics and clinical variables were associated with 2 definitions of treatment response, including 1) a reduction in mean daily urgency incontinence episodes during 6 months and 2) a 50% or greater decrease in urgency incontinence episodes across 6 months. The OAB-S (Overactive Bladder-Satisfaction) questionnaire was used to assess satisfaction.

RESULTS

A greater reduction in mean daily urgency incontinence episodes was associated with higher HUI-3 (Health Utility Index-3) scores in the onabotulinumtoxinA group and higher baseline incontinence episodes (each p <0.001) in the 2 groups. Increased age was associated with a lesser decrease in incontinence episodes in the 2 groups (p <0.001). Increasing body mass index (adjusted OR 0.82/5 points, 95% CI 0.70-0.96) was associated with reduced achievement of a 50% or greater decrease in incontinence episodes after each treatment. Greater age (adjusted OR 0.44/10 years, 95% CI 0.30-0.65) and a higher functional comorbidity index (adjusted OR 0.84/1 point, 95% CI 0.71-0.99) were associated with reduced achievement of a 50% or greater decrease in urgency incontinence episodes in the onabotulinumtoxinA group only (p <0.001 and 0.041, respectively). In the onabotulinumtoxinA group increased satisfaction was noted with higher HUI-3 score (p = 0.002) but there was less satisfaction with higher age (p = 0.001).

CONCLUSIONS

Older women with multiple comorbidities, and decreased functional and health related quality of life had decreased treatment response and satisfaction with onabotulinumtoxinA compared to sacral neuromodulation for refractory urgency incontinence.

Public Health Follow-up of Suspected Exposure to Echinococcus multilocularis in Southwestern Ontario

In the 3 years since the first report of canine alveolar echinococcosis (AE) in Ontario, three additional cases have been diagnosed in the province. Of the four cases reported to date, three have had no known history of travel outside the province. It is possible that this development is an indication of previously unrecognized environmental contamination with Echinococcus multilocularis eggs in some areas of the province. If so, there is the potential for an emerging threat to human health. This article describes a local public health department's investigation of the possible exposure to E. multilocularis of a number of individuals who had had contact with the latest of the four cases of canine AE, and summarizes a comprehensive decision process that can be used by public health departments to assist in the follow-up of such exposures.

Applicatons of Ink-Jet Printing Technology to BioMEMS and Microfluidic Systems

Applications of microfluidics and MEMS (micro-electromechanical systems) technology are emerging in many areas of biological and life sciences. Non-contact microdispensing systems for accurate, high-throughput deposition of bioactive fluids can be an enabling technology for these applications. In addition to bioactive fluid dispensing, ink-jet based microdispensing allows integration of features (electronic, photonic, sensing, structural, etc.) that are not possible, or very difficult, with traditional photolithographic-based MEMS fabrication methods.

Our single fluid and multifluid (MatrixJet™) piezoelectric microdispensers have been used for spot synthesis of peptides, production of microspheres to deliver drugs/biological materials, microprinting of biodegradable polymers for cell proliferation in tissue engineering applications, and spot deposition for DNA, diagnostic immunoassay, antibody and protein arrays. We have created optical elements, sensors, and electrical interconnects by microdeposition of polymers and metal alloys. We have also demonstrated the integration of a reversed phase microcolumn within a piezoelectric dispenser for use in the fractionation of peptides for mass spectrometer analysis.

Defining Communication Improvement Needs in General Surgery: An Analysis of Pages, Communications, Patterns, and Content☆?>

OBJECTIVE

To describe patterns of pages communication to general surgery (GS) residents, identify the need for and develop strategies to improve interprofessional communication.

DESIGN

Retrospective cohort study.

SETTING

General surgery (GS) service at a tertiary care academic institution, Sunnybrook Health Sciences Centre, in Toronto, Ontario, Canada.

PARTICIPANTS

All pages sent to GS residents over 4 weeks at an academic institution. Timing, training level of receiver and content of pages were captured.

RESULTS

Communication priority was assigned by 2 independent reviewers-low (121+ min), medium (31-120min), high (6-30min), and immediate (0-5min) priority. Overall, 2 independent reviewers analyzed pages' content through an inductive process, and generated themes. Of 2025 pages retrieved, 963 (47.5%) contained exclusively a call back number. A median of 74 pages per day (range: 43-116) were received, with median page interval of 9.4 minutes (range: 0-640). Junior residents received 79.5% of pages. Timing of the pages was 43.9% weekday shift, 31.8% weeknight shift, and 24.3% weekend call. Communication priority was deemed low for 35.4% of pages, medium for 32.3%, high for 12.4%, and immediate for 0.7%. Content analysis of 1062 pages generated 5 major themes: nonurgent medical issue (54.0%), administrative (15.3%), communication (13.5%), emergencies (4.8%), and GS consultation requests (4.0%). Priority and content of pages varied according to training level and page timing.

CONCLUSIONS

Pages to GS residents were frequent and most often of low priority. They were seldom related to urgent medical matters. Education and new communication strategies are warranted to reduce low priority pages.

Association between health literacy and 30-day healthcare use after hospital discharge in the heart failure population

BACKGROUND

Low health literacy increases the risk for hospital readmissions. Despite this, the measurement and use of health literacy to guide discharge counseling and planning in heart failure patients is not commonly performed. A short 3-Question Brief Health Literacy Screen (BHLS) is available and takes less than three minutes to complete, but has never been evaluated to help determine whether health literacy affects healthcare use after discharge in patients with heart failure.

OBJECTIVE

The purpose of this study was to assess 30-day readmissions and emergency department visits based on health literacy evaluated by the BHLS in an acute care heart failure population.

METHODS

This was a prospective observational cohort study conducted at a large quaternary health system. Hospitalized patients with a diagnosis of heart failure were assessed for health literacy using the BHLS. Unplanned healthcare use after discharge including 30-day, all-cause ED visits and hospital readmissions was assessed using univariate and logistic regression models.

RESULTS

Two hundred and sixty four patients aged 66.6 ± 14.3 (mean ± SD) years met inclusion/exclusion criteria of whom 175 (66.3%) had a BHLS score >9 (adequate health literacy) and 89 (33.7%) had a BHLS score ≤9 (low health literacy). Predictors of low health literacy included older age (p = 0.019), lower education level (p < 0.001) and unemployed (p = 0.048). After controlling for potential confounders, low health literacy was independently associated with 30-day healthcare use after hospital discharge (OR:1.80; 95% CI: 1.04-3.11; p = 0.035).

CONCLUSION

Using a short, 3-question validated survey instrument, it was demonstrated that low health literacy was associated with increased 30-day unplanned healthcare use after discharge in this heart failure population. These results provide a clinically useful, easily incorporated tool that could identify high-risk patients at need for clinical interventions.

Toward a Theory of Self-Directed Learning: a Study of Experts Without Formal Training

The authors analyzed the biographies of twenty acknowledged experts with out formal training beyond high school in search of commonalities that might suggest ways people become effectively self-directed in learning and accom plishment. Of the 154 characteristics identified, the fifty rated as most im portant were examined. They outline a pattern of education that is sharply focussed, active, experiential, self-directed, situational, and often personally challenging. They indicate a personality that is both traditional and radical, and they suggest a life theme of gathering purpose and drive. The authors transform their analyses into fourteen hypotheses about education, about a form of schooling that would prepare students for a life of self-directed learning and attainment.

Clinical manifestations and coronary artery disease risk factors at diagnosis of systemic lupus erythematosus: data from an international inception cohort

Systemic Lupus International Collaborating Clinics (SLICC) comprises 27 centres from 11 countries. An inception cohort of 918 SLE patients has been assembled according to a standardized protocol between 2000 and 2006. Clinical features, classic coronary artery disease (CAD) risk factors, as well as other potential risk factors were collected. Of the 918 patients 89% were females, and of multi racial origin. Less than half the patients were living in a permanent relationship, 58% had post secondary education and 51% were employed. Eight percent had family history of SLE. At enrolment, with at mean age of diagnosis of 34.5 years, a significant number of patients already had CAD risk factors, such as hypertension (33%) and hypercholesterolemia (36%). Only 15% of the patients were postmenopausal, 16% were current smokers and 3.6% had diabetes at entry to the SLICC-RAS (Registry for Atherosclerosis). A number of patients in this multi-racial, multi-ethnic inception cohort of lupus patients have classic CAD risk factors within a mean of 5.4 months from diagnosis. This cohort will be increased to 1500 patients to be followed yearly for 10 years. This will provide a unique opportunity to evaluate risk factors for accelerated atherosclerosis in SLE. Lupus (2007) 16, 731—735.

Expansion of clinical pharmacy through increased use of outpatient pharmacists for anticoagulation services

PURPOSE

The expansion of clinical pharmacy services through increased use of outpatient pharmacists for anticoagulation services is described.

SUMMARY

Due to the high demand for clinical pharmacist services by patients and medical staff at Harris Health System in Houston, Texas, and the strict budgetary restrictions to improve the quality of care through cost-neutral services, a new telephone anticoagulation monitoring service, provided by clinical pharmacists, was established at four of the busiest anticoagulation ambulatory care centers within the system. One clinical staff pharmacist was trained in each of the four clinics by a clinical pharmacy specialist. Each pharmacist received roughly two weeks of training to provide this service. Implementation of the new anticoagulation monitoring service occurred on April 1, 2013. Data collected between October 2011 and April 2014 revealed significantly more visits per month for the clinical pharmacy service after the implementation of the telephone anticoagulation monitoring service (p=0.011). Redistribution of workflow resulted in a 16% increase in clinical pharmacy patient volume at the ambulatory care clinics (p=0.011). The percentage of International Normalized Ratio values in the therapeutic range, the proportion of hospitalizations due to thromboembolic or bleeding events, work hours per prescription volume, project completion rates, and the number of students precepted did not significantly differ between groups.

CONCLUSION

The implementation of a clinical pharmacy telephone service for patients receiving anticoagulation at an outpatient center resulted in increased patient clinic visits without adversely affecting patient outcomes or increasing personnel or costs.

Lower limb kinematics of male and female soccer players during a self-selected cutting maneuver: Effects of prolonged activity

BACKGROUND

Despite the recent emphasis on injury prevention, anterior cruciate ligament (ACL) injury rates remain high. This study aimed to ascertain the effects of prolonged activity on lower limb kinematics during a self-selected cutting maneuver.

METHODS

Angular kinematics were recorded during an agility test performed until the completion time was greater than the mean plus one SD of baseline trials. Cut type was identified and the hip and knee angles at 33 ms post heel strike were determined. A linear mixed effects model assessed the effects of cut type, gender, and activity status on the hip and knee angles.

RESULTS

Males performed sidestep cuts more frequently than females. Females increased the incidence of sidestep cuts after prolonged activity. At the hip, a gender-cut type interaction existed for the transverse (p=0.001) and sagittal (p=0.11) planes. Females showed more internal rotation during sidestep and more external rotation and less flexion during crossover cuts. For the frontal plane, a gender-activity status interaction (p = 0.032) was due to no change within females but greater hip adduction during prolonged activity within males. With prolonged activity, both genders displayed less hip (p=0.29) and knee (p=0.009) flexion and more knee (p=0.001) adduction. Females displayed less hip and knee flexion than men (p=0.001).

CONCLUSIONS

Sidestep may be more risky than crossover cuts. Both genders place themselves in at-risk postures with prolonged activity due to less hip and knee flexion.

Waterborne toxicity and diet-related effects of fungicides in the key leaf shredder Gammarus fossarum (Crustacea: Amphipoda)

Animals involved in leaf litter breakdown (i.e., shredders) play a central role in detritus-based stream food webs, while their fitness and functioning can be impaired by anthropogenic stressors. Particularly fungicides can affect shredders via both waterborne exposure and their diet, namely due to co-ingestion of adsorbed fungicides and shifts in the leaf-associated fungal community, on which shredders' nutrition heavily relies. To understand the relevance of these effect pathways, we used a full 2×2-factorial test design: the leaf material serving as food was microbially colonized for 12 days either in a fungicide-free control or exposed to a mixture of five current-use fungicides (sum concentration of 62.5μg/L). Similarly, the amphipod shredder Gammarus fossarum was subjected to the same treatments but for 24 days. Waterborne exposure reduced leaf consumption by ∼20%, which did not fully explain the reduction in feces production (∼30%), indicating an enhanced utilization of food to compensate for detoxification mechanisms. This may also explain the reduced feces production (∼10%) of gammarids feeding on fungicide-exposed leaves. The reduction may, however, also be caused by a decreased nutritious quality of the leaves indicated by a reduced species richness (∼40%) of leaf-associated fungi. However, compensation for these effects by Gammarus was seemingly incomplete, since both waterborne exposure and the consumption of the fungicide-affected diet drastically reduced gammarid growth (∼110% and ∼40%, respectively). Our results thus indicate that fungicide mixtures have the potential for detrimental implications in aquatic ecosystem functioning by affecting shredders via both effect pathways.

What Aspects of Personal Care Are Most Important to Patients Undergoing Radiation Therapy for Prostate Cancer?

PURPOSE/OBJECTIVE

The overall quality of patient care is a function of the quality of both its technical and its nontechnical components. The purpose of this study was to identify the elements of nontechnical (personal) care that are most important to patients undergoing radiation therapy for prostate cancer.

METHODS AND MATERIALS

We reviewed the literature and interviewed patients and health professionals to identify elements of personal care pertinent to patients undergoing radiation therapy for prostate cancer. We identified 143 individual elements relating to 10 aspects of personal care. Patients undergoing radical radiation therapy for prostate cancer completed a self-administered questionnaire in which they rated the importance of each element. The overall importance of each element was measured by the percentage of respondents who rated it as "very important." The importance of each aspect of personal care was measured by the mean importance of its elements.

RESULTS

One hundred eight patients completed the questionnaire. The percentage of patients who rated each element "very important" ranged from 7% to 95% (mean 61%). The mean importance rating of the elements of each aspect of care varied significantly: "perceived competence of caregivers," 80%; "empathy and respectfulness of caregivers," 67%; "adequacy of information sharing," 67%; "patient centeredness," 59%; "accessibility of caregivers," 57%; "continuity of care," 51%; "privacy," 51%; "convenience," 45%; "comprehensiveness of services," 44%; and "treatment environment," 30% (P<.0001). Neither age nor education was associated with importance ratings, but the patient's health status was associated with the rating of some elements of care.

CONCLUSIONS

Many different elements of personal care are important to patients undergoing radiation therapy for prostate cancer, but the 3 aspects of care that most believe are most important are these: the perceived competence of their caregivers, the empathy and respectfulness of their caregivers, and the adequacy of information sharing.

Primary osseous tumours of the elbow: 60 years of registry experience

BACKGROUND

We present the largest series of surgically treated primary bone tumours of the elbow in the English literature (75 cases). We sought to identify characteristics specific to these lesions and recommend an investigatory protocol.

METHODS

The national registry and case notes were reviewed between 1954-2014. Tumours were classified according to Enneking's spectrum.

RESULTS

There were no benign latent cases in this series as these were managed locally. All patients presented with persistent rest pain, with or without swelling. The distal humerus, in contrast to the proximal radius and ulna, was responsible for the majority and the more aggressive cases. Misdiagnosis was evident in 13% of cases; most of which were attributed to simple bone cysts. All patients that were referred required surgical intervention to either establish the diagnosis or for treatment. Benign tumours had a 19% recurrence rate, with giant cell tumour the most aggressive. Malignant tumours carried 39% local recurrence rate and a 5-year mortality of 61%.

CONCLUSIONS

The suspicion of a tumour should be raised in the patient with unremitting, unexplained, non-mechanical bony elbow pain. These echo the NICE recommendations and we recommend prompt specialist referral. With high rates of local recurrence, we recommend close postoperative monitoring.

The relative importance of diet-related and waterborne effects of copper for a leaf-shredding invertebrate

Copper (Cu) exposure can increase leaf-associated fungal biomass, an important food component for leaf-shredding macroinvertebrates. To test if this positive nutritional effect supports the physiological fitness of these animals and to assess its importance compared to waterborne toxicity, we performed a 24-day-bioassay in combination with a 2×2 factorial design using the amphipod shredder Gammarus fossarum and a field-relevant Cu concentration of 25 μg/L (n = 65). Waterborne toxicity was negligible, while gammarids fed leaves exposed to Cu during microbial colonization exhibited a near-significant impairment in growth (∼30%) and a significantly reduced lipid content (∼20%). These effects appear to be governed by dietary uptake of Cu, which accumulated in leaves as well as gammarids and likely overrode the positive nutritional effect of the increased fungal biomass. Our results suggest that for adsorptive freshwater contaminants dietary uptake should be evaluated already during the registration process to safeguard the integrity of detritus-based ecosystems.

Towards allele-level human leucocyte antigens genotyping - assessing two next-generation sequencing platforms: Ion Torrent Personal Genome Machine and Illumina MiSeq

Human leucocyte antigens (HLA) typing has been a challenge due to extreme polymorphism of the HLA genes and limitations of the current technologies and protocols used for their characterization. Recently, next-generation sequencing techniques have been shown to be a well-suited technology for the complete characterization of the HLA genes. However, a comprehensive assessment of the different platforms for HLA typing, describing the limitations and advantages of each of them, has not been presented. We have compared the Ion Torrent Personal Genome Machine (PGM) and Illumina MiSeq, currently the two most frequently used platforms for diagnostic applications, for a number of metrics including total output, quality score per position across the reads and error rates after alignment which can all affect the accuracy of HLA genotyping. For this purpose, we have used one homozygous and three heterozygous well-characterized samples, at HLA-A, HLA-B, HLA-C, HLA-DRB1 and HLA-DQB1. The total output of bases produced by the MiSeq was higher, and they have higher quality scores and a lower overall error rate than the PGM. The MiSeq also has a higher fidelity when sequencing through homopolymer regions up to 9 bp in length. The need to set phase between distant polymorphic sites was more readily achieved with MiSeq using paired-end sequencing of fragments that are longer than those obtained with PGM. Additionally, we have assessed the workflows of the different platforms for complexity of sample preparation, sequencer operation and turnaround time. The effects of data quality and quantity can impact the genotyping results; having an adequate amount of good quality data to analyse will be imperative for confident HLA genotyping. The overall turnaround time can be very comparable between the two platforms; however, the complexity of sample preparation is higher with PGM, while the actual sequencing time is longer with MiSeq.

Determining appropriate imaging parameters for kilovoltage intrafraction monitoring: an experimental phantom study

Kilovoltage intrafraction monitoring (KIM) utilises the kV imager during treatment for real-time tracking of prostate fiducial markers. However, its effectiveness relies on sufficient image quality for the fiducial tracking task. To guide the performance characterisation of KIM under different clinically relevant conditions, the effect of different kV parameters and patient size on image quality, and quantification of MV scatter from the patient to the kV detector panel were investigated in this study. Image quality was determined for a range of kV acquisition frame rates, kV exposure, MV dose rates and patient sizes. Two methods were used to determine image quality; the ratio of kV signal through the patient to the MV scatter from the patient incident on the kilovoltage detector, and the signal-to-noise ratio (SNR). The effect of patient size and frame rate on MV scatter was evaluated in a homogeneous CIRS pelvis phantom and marker segmentation was determined utilising the Rando phantom with embedded markers. MV scatter incident on the detector was shown to be dependent on patient thickness and frame rate. The segmentation code was shown to be successful for all frame rates above 3 Hz for the Rando phantom corresponding to a kV to MV ratio of 0.16 and an SNR of 1.67. For a maximum patient dimension less than 36.4 cm the conservative kV parameters of 5 Hz at 1 mAs can be used to reduce dose while retaining image quality, where the current baseline kV parameters of 10 Hz at 1 mAs is shown to be adequate for marker segmentation up to a patient dimension of 40 cm. In conclusion, the MV scatter component of image quality noise for KIM has been quantified. For most prostate patients, use of KIM with 10 Hz imaging at 1 mAs is adequate however image quality can be maintained and imaging dose reduced by altering existing acquisition parameters.