Combining exercise, protein supplementation and electric stimulation to mitigate muscle wasting and improve outcomes for survivors of critical illness-The ExPrES study

BACKGROUND

Neuromuscular electrical stimulation (NMES) with high protein supplementation (HPRO) to preserve muscle mass and function has not been assessed in ICU patients. We compared the effects of combining NMES and HPRO with mobility and strength rehabilitation (NMES+HPRO+PT) to standardized ICU care.

OBJECTIVES

To assess the effectiveness of combined NMES+HPRO+PT in mitigating sarcopenia as evidenced by CT volume and cross-sectional area when compared to usual ICU care. Additionally, we assessed the effects of the combined therapy on select clinical outcomes, including nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

METHODS

Participants were randomized by computer generated assignments to receive either NMES+HPRO+PT or standard care. Over 14 days the standardized ICU care group (N = 23) received usual critical care and rehabilitation while the NMES+HPRO+PT group (N = 16) received 30 min neuromuscular electrical stimulation of quadriceps and dorsiflexors twice-daily for 10 days and mean 1.3 ± 0.4 g/kg body weight of high protein supplementation in addition to standard care. Nonresponsive participants received passive exercises and, once responsive, were encouraged to exercise actively. Primary outcome measures were muscle volume and cross-sectional area measured using CT-imaging. Secondary outcomes included nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

RESULTS

The NMES+HPRO+PT group (N = 16) lost less lower extremity muscle volume compared to the standard care group (N = 23) and had larger mean combined thigh cross-sectional area. The nitrogen balance remained negative in the standard care group, while positive on days 5, 9, and 14 in the NMES+HPRO+PT group. Standard care group participants experienced more delirium than the NMES+HPRO+PT group. No differences between groups when comparing length of stay or mechanical ventilation days.

CONCLUSIONS

The combination of neuromuscular electrical stimulation, high protein supplementation and mobility and strength rehabilitation resulted in mitigation of lower extremity muscle loss and less delirium in mechanically ventilated ICU patients.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02509520. Registered July 28, 2015.

VIRTUAL NUTRITION EDUCATION AND PRODUCE DELIVERY INCREASES DIETARY QUALITY AMONG OLDER VETERANS

This project assessed the impact of a 14-week virtual group nutrition education plus produce delivery on diet quality of Baltimore GEROFIT participants. RD led classes focused on healthy aging content. Participants could receive an optional bag of local produce. Dietary intake assessed via a 24-hour recall was used to calculate healthy eating index (HEI-2015; higher scores=higher diet quality). Twelve participants enrolled in the program. Two participants discontinued produce delivery due to physical/environmental limitations prohibiting preparation; seven completed recalls at pre/post and received produce (86% male; 71% Caucasian; age=73 years; BMI=33 kg/m2). There were no changes in overall diet. However, among participants who received >80% of produce (n=4), HEI scores increased (+5.4 points). Daily F&V increased by 1.9 servings. Daily protein intake decreased (-25g). This study highlights areas for program improvement including a stronger emphasis on protein intake and incorporating physical/environmental adaptations that may increase participation among older Veterans with disabilities.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Electronic Screening for Adolescent Risk Behaviors in the Emergency Department: A Randomized Controlled Trial

Introduction: In this study we aimed to assess the impact of an electronic health assessment with individualized feedback for risk behaviors in adolescents seeking care in a pediatric emergency department (ED). Methods: We conducted a randomized control trial using a tablet-based screening program with a study population of adolescents in a busy pediatric ED. The intervention group received the screening program with individualized feedback. The control group received the screening program without feedback. All participants received one-day and three-month follow-up surveys to assess behaviors and attitudes toward health behaviors. Results: A total of 296 subjects were enrolled and randomized. There was no difference in changes in risky behaviors between the control and experimental groups. A higher proportion of participants in the intervention groups reported that the screener changed the way they thought about their health at one-day follow-up (27.0%, 36/133) compared to the control group (15.5%, 20/129, P = .02). Conclusion: This study successfully tested a multivariable electronic health screener in a real-world setting of a busy pediatric ED. The tool did not significantly change risky health behaviors in the adolescent population screened. However, our finding that the intervention changed adolescents’ perceptions of their health opens a door to the continued development of electronic interventions to screen for and target risk behaviors in adolescents in the ED setting.

1,3-Dioxane-Linked Novel Bacterial Topoisomerase Inhibitors: Expanding Structural Diversity and the Antibacterial Spectrum

Antibacterial resistance continues its devastation of available therapies. Novel bacterial topoisomerase inhibitors (NBTIs) offer one solution to this critical issue. Two series of amine NBTIs bearing tricyclic DNA-binding moieties as well as amide NBTIs with a bicyclic DNA-binding moiety were synthesized and evaluated against methicillin-resistant Staphylococcus aureus (MRSA). Additionally, these compounds and a series of bicyclic amine analogues displayed high activity against susceptible and drug-resistant Neisseria gonorrhoeae, expanding the spectrum of these dioxane-linked NBTIs.

Robust Institutional Support and Collaboration Between Summer Training Programs in Cancer and Biomedicine Drive the Pivot to a Virtual Format in Response to the COVID Pandemic

Summer internships serve important roles in training the next generation of biomedical researchers and healthcare providers through laboratory and clinical experiences that excite trainees about these fields and help them make informed decisions about career paths. The SARS-CoV-2 (COVID) pandemic and associated physical distancing restrictions precluded implementation of traditional in-person summer curricula and led to the cancellation of many internships across the USA. COVID-related disruptions also created opportunities for trainees to engage in remote research, become proficient in online learning platforms, and explore multidisciplinary topics. These skills are highly relevant to trainees as virtual interfaces occupy an increasingly mainstream role in their professional paths. The response to the COVID pandemic required real-time adaptations at all levels for major biomedical institutions including the University of Maryland Baltimore (UMB). Pivoting summer programs to a virtual format as part of this response provided a "teachable moment" to expose trainees to the innovation and resilience that are essential components of the biomedical profession. UMB summer programs, which span diverse biomedical disciplines from cancer research to diabetes, consolidated resources and identified mentors with online research projects to develop a robust virtual curriculum. Herein, data from a cancer-focused internship illustrate the collaborative adaptations to established components and creation of new learning modules in the transition to, and implementation of, online training. Outcomes are presented in the context of the COVID pandemic and significant societal issues that arose in the summer of 2020. The utility of virtual components and their impact on future programs is discussed.

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Electronic Screening, Feedback, and Clinician Training in Adolescent Primary Care: A Stepped-Wedge Cluster Randomized Trial

PURPOSE

The aim of this study is to test the effects of an electronic screening and feedback tool and training for primary care clinicians on care and adolescent health behaviors.

METHODS

We conducted a stepped-wedge cluster randomized trial with six clinics randomly assigned to sequential crossover from control to intervention periods with clinician training between periods. Adolescents (ages 13-18) with a well visit during the control periods (n = 135) received usual care, while adolescents during the intervention periods (n = 167) received the electronic screening and feedback tool prior to their well visit, with results sent to their clinicians. Adolescents completed surveys at baseline, 1 day, 3 months, 6 months, and 12 months. Linear mixed effects models were used to examine associations between outcomes and treatment, controlling for time as a fixed effect and clinic as a random effect. All analyses employed intent-to-treat analyses and utilized multiple imputations for missing data.

RESULTS

Adolescents who received the intervention had a higher rate of counseling for their endorsed risk behaviors during the well visit (45% vs. 33%, Wald's T = 2.29, p = .02). There were no significant intervention effects on adolescent satisfaction with the clinician or perception of patient centeredness. The intervention was associated with a small but statistically significant reduction in overall risk score relative to control at 3 months (-.63, 95% confidence interval [-1.07, -.19], Cohen's d = .21), but not at 6 or 12 months.

CONCLUSIONS

The results suggest that electronic screening and feedback may be associated with small reductions in risk behaviors at 3 months but that changes do not persist at longer term follow-up.

Developing a predictive model for spinal shock in dogs with spinal cord injury

BACKGROUND

Reduced pelvic limb reflexes in dogs with spinal cord injury typically suggests a lesion of the L4-S3 spinal cord segments. However, pelvic limb reflexes might also be reduced in dogs with a T3-L3 myelopathy and concurrent spinal shock.

HYPOTHESIS/OBJECTIVES

We hypothesized that statistical models could be used to identify clinical variables associated with spinal shock in dogs with spinal cord injuries.

ANIMALS

Cohort of 59 dogs with T3-L3 myelopathies and spinal shock and 13 dogs with L4-S3 myelopathies.

METHODS

Data used for this study were prospectively entered by partner institutions into the International Canine Spinal Cord Injury observational registry between October 2016 and July 2019. Univariable logistic regression analyses were performed to assess the association between independent variables and the presence of spinal shock. Independent variables were selected for inclusion in a multivariable logistic regression model if they had a significant effect (P ≤ .1) on the odds of spinal shock in univariable logistic regression.

RESULTS

The final multivariable model included the natural log of weight (kg), the natural log of duration of clinical signs (hours), severity (paresis vs paraplegia), and pelvic limb tone (normal vs decreased/absent). The odds of spinal shock decreased with increasing weight (odds ratio [OR] = 0.28, P = .09; confidence interval [CI] 0.07-1.2), increasing duration (OR = 0.44, P = .02; CI 0.21-0.9), decreased pelvic limb tone (OR = 0.04, P = .003; CI 0.01-0.36), and increased in the presence of paraplegia (OR = 7.87, P = .04; CI 1.1-56.62).

CONCLUSIONS AND CLINICAL IMPORTANCE

A formula, as developed by the present study and after external validation, could be useful for assisting clinicians in determining the likelihood of spinal shock in various clinical scenarios and aid in diagnostic planning.

Nutritional Risk and Health-Related Quality of Life in Older Adults Aging With HIV

Due to antiretroviral treatment success, individuals with HIV are living longer. People aging with HIV (PAWH, 50+) may be more likely to experience nutritional risk compared to their HIV-negative counterparts due to biopsychosocial factors. The DETERMINE checklist measure accounts for social and economic factors as well as aspects of the aging process that are not typically considered when examining nutritional risk and are important for PAWH. The current study examined nutritional risk and health-related quality of life (HRQoL) in PAWH using the DETERMINE checklist and PROMIS t-scores (mental and physical HRQoL) through secondary analyses of 158 participants in the Strengthening Therapeutic Resources in Older patients agiNG with HIV (STRONG) study. DETERMINE nutritional risk scores (0-21) were separated into 4 groups (low-risk [0-2, n=13], moderate-risk [3-5, n=28], high-risk [6-12, n=78], very high-risk [13-21, n=39]). The sample was 55% male, 94% Black/African American and had a mean age=59 (SD=5.5). Most of the sample (74%) were at high or very high nutritional risk and low HRQoL t-score: physical M=43.7 (SD=9.5), and mental M=45.7 (SD=10.1). Mental and physical HRQoL were significantly (p<.001) associated with nutritional risk group as tested through linear regressions. Means were as follows: physical HRQoL low-risk M=53.4 (SD=10.6), moderate-risk M=47.4 (SD=8.9), high-risk M=43.5 (SD=8.1), very high-risk M=38.4 (SD=8.9); mental HRQoL low-risk M=54.0 (SD=8.9), moderate-risk M=49.1(SD=7.9), high-risk M=46.1(SD=9.5), and very high-risk M=39.5 (SD=9.7). These associations remained significant after controlling for age and sex. Higher nutritional risk as measured by the DETERMINE checklist in PAWH was associated with poorer physical and mental HRQoL.

Disparities in Local Wellness Policies Implementation Across Maryland Schools

BACKGROUND

School-level implementation of district-level local wellness policies (LWPs) is needed to create school environments that promote nutrition and physical activity (PA). Disparities in classroom-specific LWPs implementation were examined.

METHODS

An administrator survey (N = 756 schools; 24/24 districts) included 6 classrooms LWP best-practice items (fully/not fully implemented: restricting food celebrations or rewards, incorporating PA breaks or integrating PA in curricula, restricting withholding or using PA as punishment). A sum score (alpha = .71; elementary and middle/high examined separately) was used to examine associations with student body income (free-and-reduced priced meals (FARMS): ≤40%, 41-75%, ≥75%), race/ethnicity, and school location (rural/urban/suburban), accounting for district-level clustering, with moderation examined.

RESULTS

Classroom implementation scores were: elementary = 3.1 ± 1.8 (range: 0-6/6 items) and middle/high = 2.3 ± 1.6 (range:0-5/5 items). Among elementary and middle/high schools, 65% and 55% had >40% FARMS, 39% and 46% had ≥50% white student body, and 24% and 23% were urban, respectively. Elementary schools with >40% of FARMS-eligible students and middle/high schools with <25% white students reported implementing fewer items. Location was not associated with classroom practices nor was moderation observed.

CONCLUSIONS

Disparities in classroom-specific LWP best practices implementation were observed by income and race/ethnicity. Tailored support may be needed to improve classroom LWP implementation in schools serving low-income students.

AmpC- and Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae Detected in Fresh Produce in Central Ohio

ABSTRACT

Salad vegetables purchased from farmer's markets and grocery stores in central Ohio during the summers of 2015 and 2016 were tested for the presence of Enterobacteriaceae resistant to extended-spectrum cephalosporins and carbapenems, Salmonella contamination, and coliform bacterial counts. A total of 364 samples were collected from 36 farmers' markets and 33 grocery stores. Using selective media, we found 23 (6.3%) samples that produced Enterobacteriaceae expressing an AmpC β-lactamase phenotype, with 11 (3.0%) confirmed to contain blaCMY and 6 (1.6%) that produced Enterobacteriaceae with an extended-spectrum β-lactamase (ESBL) phenotype, 1 (0.3%) of which was confirmed to contain blaCTX-M. All blaCMY and blaCTX-M strains were isolated from leafy greens. No Salmonella spp. or carbapenem-resistant Enterobacteriaceae were recovered from fresh produce samples. Adjusting for year, the geometric mean coliform count differed (P < 0.05) between produce types, with the count in tomatoes (15 CFU/mL) being lower than those in cucumbers (77.4 CFU/mL) and leafy greens (75.0 CFU/mL). The coliform counts also differed (P < 0.05) between years, with 19.6 CFU/mL in 2015 and 96.0 CFU/mL in 2016. There was no difference in coliform counts or the prevalences of Enterobacteriaceae expressing AmpC or ESBL phenotypes in produce purchased from farmers' markets and grocery stores.

HIGHLIGHTS

Changes in Self-Reported Fruit and Vegetable Intake following Nutritional Modification in High Risk Older Veterans

This project aimed to determine the feasibility of implementing a dietary intervention in older Veterans participating in an exercise and health promotion program (Gerofit) and whether this intervention could improve self-reported fruit and vegetable (F&V) intake measured by BRFSS and diet quality measured by visual analog scale (0-10 scale). Participation consisted of optional group and individual counseling with a Registered Dietitian (RD). Out of 50 participants approached to participant in the program, 24 Veterans attended ≥2 group sessions (2.9 ± 2.0 classes, which was 82% of total available sessions). There was a reported trend toward increased daily F&V intake (pre vs. post: 3.4 ± 1.9 vs. 4.1 ± 2.0 servings/day, p = 0.07) and a significant increase in diet quality (4.7 ± 0.5 vs. 5.9 ± 0.4, p= 0.03) from baseline compared to the last attended class. These promising preliminary findings can be used to inform efforts to optimize dietary intake in vulnerable Veteran populations.

Multi-tissue epigenetic analysis of the osteoarthritis susceptibility locus mapping to the plectin gene PLEC

OBJECTIVE

In cartilage, the osteoarthritis (OA) associated single nucleotide polymorphism (SNP) rs11780978 correlates with differential expression of PLEC, and with differential methylation of PLEC CpG dinucleotides, forming eQTLs and mQTLs respectively. This implies that methylation links chondrocyte genotype and phenotype, thus driving the functional effect of this genetic risk signal. PLEC encodes plectin, a cytoskeletal protein that enables tissues to respond to mechanical forces. We sought to assess whether these PLEC functional effects were cartilage specific.

METHOD

Cartilage, fat pad, synovium and peripheral blood were collected from patients undergoing arthroplasty. PLEC CpGs were analysed for mQTLs and allelic expression imbalance (AEI) was performed to test for eQTLs. Plectin was knocked down in a mesenchymal stem cell (MSC) line using CRISPR/Cas9 and cells phenotyped by RNA-sequencing.

RESULTS

mQTLs were discovered in fat pad, synovium and blood. Their effects were however stronger in the joint tissues and of comparable effect between these tissues. We observed AEI in synovium in the same direction as for cartilage and correlations between methylation and PLEC expression. Knocking-down plectin impacted on pathways reported to have a role in OA, including Wnt signalling, glycosaminoglycan biosynthesis and immune regulation.

CONCLUSIONS

Synovium is also a target of the rs11780978 OA association functionally operating on PLEC. In fat pad, mQTLs were identified but these did not correlate with PLEC expression, suggesting the functional effect is not joint-wide. Our study highlights interplay between genetic risk, DNA methylation and gene expression in OA, and reveals clear differences between tissues from the same diseased joint.

Study protocol for a randomised controlled trial investigating two different refeeding formulations to improve safety and efficacy of hospital management of adolescent and young adults admitted with anorexia nervosa

INTRODUCTION

Providing effective nutritional rehabilitation to patients hospitalised with anorexia nervosa (AN) is challenging, partly due to conservative recommendations that advocate feeding patients at low energy intakes. An 'underfeeding syndrome' can develop when patients are not provided with adequate nutrition during treatment, whereby malnourished patients fail to restore weight in a timely matter, and even lose weight. Of particular concern, the reintroduction of carbohydrate in a starved patient can increase the risk of developing electrolyte, metabolic and organ dysfunction. The proposed trial assesses the efficacy and safety of a lower carbohydrate enteral formula (28% carbohydrate) against a standard enteral formula (54% carbohydrate), in adolescent and young adult patients (aged 15-25 years), hospitalised with AN.

METHODS AND ANALYSIS

The study employs a double-blind randomised controlled trial design. At admission to hospital, malnourished adolescent and young adults with AN will be randomly allocated to commence feeding on a standard enteral feeding formula (1.5 kcal/mL, 54% carbohydrate) or a lower carbohydrate isocaloric enteral feeding formula (1.5 kcal/mL, 28% carbohydrate). Assessments of nutritional intake, weight and biochemistry (phosphate, magnesium, potassium) will be conducted at baseline and during the first 3 weeks of hospital admission. The primary outcome measure will be incidence of hypophosphatemia. Secondary outcomes include weight gain, oedema, other electrolyte distortion, length of hospital admission, admission to the Intensive Care Unit (ICU) and number of days to reach medical stability, using defined parameters.

ETHICS AND DISSEMINATION

The protocol was approved by the Western Sydney Local Health District Human Research Ethics Committee and institutional research governance approvals were granted. Written informed consent will be sought prior to study enrolment. Study findings will be widely disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12617000342314); Pre-results.

Long-term clinical and magnetic resonance imaging follow-up of dogs with osseous-associated cervical spondylomyelopathy

BACKGROUND

Osseous-associated cervical spondylomyelopathy (OA-CSM) is a complex disorder with limited long-term survival. The longitudinal progression is currently unknown.

OBJECTIVE

To describe changes on magnetic resonance imaging (MRI) over a 2-year minimum period. We hypothesized that spinal lesions would progress in the majority of dogs.

ANIMALS

Eleven dogs previously diagnosed with OA-CSM were prospectively studied. Nine dogs were treated medically, whereas 2 were treated surgically.

METHODS

Clinical and MRI follow-up were performed with a median time between MRI studies of 30 months (range, 24-54). Morphologic assessment evaluated vertebral canal stenosis, spinal cord compression, foraminal stenosis, and articular processes, among other variables. Morphometric assessment included vertebral canal area, spinal cord area, area of the articular processes, and foraminal height.

RESULTS

On follow-up MRI, the most affected site at the initial examination in medically treated dogs had progressed in 4 of 9 dogs, improved in 4, and was unchanged in 3. Clinically, all dogs except 2 medically treated dogs were unchanged to improve at follow-up. Initially, 50 of 60 (83.3%) intervertebral spaces had vertebral canal stenosis, whereas in the follow-up MRI 82.3% did. Of the sites with stenosis, 45.7% were unchanged, 18.6% improved, and 38.9% worsened. Morphometry identified significant decreases in vertebral canal and spinal cord areas at C4-C5 through C6-C7, and significant progression of articular process irregularities at C3-C4 and C6-C7.

CONCLUSIONS AND CLINICAL IMPORTANCE

This long-term follow-up study of dogs with OA-CSM did not identify clinical or MRI progression of lesions in the majority of dogs.

Patient-centered pathology reports for breast cancer care: Interim results of a randomized pilot study

e19157

Background: Receiving a new cancer diagnosis event is a daunting event, quickly followed by complex decision-making between patients and care teams. In order for patients to fully engage in shared decision-making with their providers, they must have access to understandable, patient-centered information that empowers them to take an active role. Yet cancer pathology reports currently target providers and are marred by complex medical terminology. To address this gap, we designed and piloted patient-centered pathology reports (PCPRs) for breast cancer surgical pathology. We hypothesized that PCPRs would result in patients having greater pathology knowledge and decisional self-efficacy. Methods: PCPRs were designed with continuous guidance from breast surgeons, pathologists, and patient advocates with the goal of providing a supplemental tool to translate standard pathology reports to layman’s terms for patients. PCPRs were built into the electronic medical record and tested for quality and accuracy over a 4-month period. Participants were recruited from the clinical practices of two breast surgeons and randomized to receive either the PCPR and standard pathology report or standard pathology report alone. Patients were surveyed at baseline and one month after to assess their breast cancer knowledge and ratings of confidence (scale 1-5) and decisional self-efficacy (DSE) for treatment decision-making (scale 0-100). Results: Of a planned 40 pilot patients, 30 have been enrolled, randomized (20 standard report patients, 10 PCPR patients), and have follow up data. Evaluation of patient knowledge showed that compared with the control group, patients who received a PCPR had similar knowledge of the important elements of their report (p = 0.10-p = 0.69) with greater specificity for those report elements. Confidence in their diagnosis slightly favored PCPR recipients (confidence rating mean 4.00 vs. 3.77 for control patients, p = 0.67). Patients receiving the PCPR had better DSE immediately after receipt of the pathology report than standard report patients (DSE 96.0 vs. 82.2, respectively, p = 0.05) with a more attenuated DSE difference one month later (DSE 87.3 vs. 79.2, respectively, p = 0.35). Conclusions: This interim analysis suggests that providing breast cancer patients with patient-centered pathology reports may contribute to an improved ability to engage in shared decision-making. Confirming these results with complete pilot data could inform a larger multicenter study to validate their effectiveness in clinical cancer care.

An audit of the changes in thiamine levels during higher caloric nutritional rehabilitation of adolescent patients hospitalised with a restrictive eating disorder

BACKGROUND

Routine supplementation of thiamine in patients with restrictive eating disorders prior to initiation of nutritional rehabilitation, is an example of a clinical guideline based on expert opinion rather than evidence-based recommendations. This study investigates whether adolescents hospitalised with a restrictive eating disorder commenced on a higher caloric refeeding regimen, present with or develop thiamine deficiency during their admission.

METHODS

An eighteen month retrospective audit of 119 consecutive admissions for nutritional rehabilitation was conducted on patients admitted with an eating disorder in a large tertiary teaching hospital in Western Sydney. Data from paper-based and electronic medical records were collected. Baseline and weekly blood thiamine levels were documented, as well as patient demographic information including admission weight, age, length of stay, percentage median body mass index, weight change throughout admission and caloric prescription.

RESULTS

Sixty admissions met inclusion criteria, mean age 17.2 years (SD 1.2); 88% female; BMI 16.8 kg/m² (SD 1.8) on admission. A linear mixed effects model identified that median thiamine levels increased by 9.2 nmol/L per week (p < 0.001). No patient developed thiamine deficiency during their admission, one patient was admitted with thiamine levels below the normal range at 62 nmol (normal range 67 - 200 nmol/L) which resolved by the second week of admission. In 15 out of 60 patients (25%), thiamine levels were observed to rise above the upper limit.

CONCLUSIONS

Nutritional management of 60 malnourished adolescents hospitalised with an eating disorder was conducted safely with the provision of only 10 mg thiamine in a multivitamin daily, and no additional thiamine supplementation. The high caloric refeeding protocol, inclusive of a daily multivitamin, provided adequate thiamine to prevent thiamine deficiency. Further research should examine thiamine requirements in an exclusive severely malnourished population to assess the need for thiamine replacement in the most vulnerable group.

Confirmatory factor analysis of the health literacy in dentistry scale (HeLD) in the Australian population

OBJECTIVE

To determine the psychometric properties of both the long- and short-form versions of the Health Literacy in Dentistry (HeLD) instrument in a large sample of the Australian adult population.

METHODS

Data were from a subset of the National Dental Telephone Interview Survey 2013. Both the long (HeLD-29) and short-form (HeLD-14) were utilised, each of which comprises items from 7 conceptual domains: access, understanding, support, utilization, economic barriers, receptivity and communication. Confirmatory Factor Analysis was performed through structural equation modelling to determine factorial validity, where the Χ²/df, comparative fit, goodness of fit and root mean square error of approximation were used as indices of goodness of fit. Convergent validity was estimated from the average variance extracted (AVE) and composite reliability (CR), while internal consistency was estimated by Cronbach standardized alpha.

RESULTS

The dataset comprised 2,936 Australian adults aged 18+ years. The kurtosis and skewness values indicated an approximation to a normal distribution. Adequate fit was demonstrated for HeLD-14, but not for HeLD-29. Estimates of ≥ 0.50 for AVE and ≥ 0.70 for CR were demonstrated across all factors for both HeLD-29 and HeLD-14, indicating acceptable convergent validity for both forms. Discriminant validity was also demonstrated for both forms. Internal consistency was adequate in the seven conceptual domains for both HeLD forms, with Cronbach's alpha for all subscales being ≥0.70.

CONCLUSIONS

The psychometric properties of the HeLD instrument in a large sample of the Australian adult population were confirmed. The short form HeLD-14 was more parsimonious than the long-form (HeLD-29).

Expanding collaborative care: integrating the role of dietitians and nutrition interventions in services for people with mental illness

OBJECTIVE

This article aims to draw mental health clinicians' attention to the connections between nutrition and mental health, and the roles that Accredited Practising Dietitians play in improving mental and physical health through dietary change.

METHODS

Selective narrative review.

RESULTS

Unhealthy dietary practices are common in high prevalence and severe mental illness. Epidemiological evidence demonstrates that nutrients and dietary patterns impact on mental health. In addition, poor physical health is well documented in people with mental illness and the greatest contributor to the mortality gap. Dietary intervention studies demonstrate improved mental and physical health outcomes. Accredited Practising Dietitians translate nutrition science into practical advice to improve the nutritional status of patients with mental illness, and prevent and manage comorbidities in a variety of care settings.

CONCLUSIONS

Medical Nutrition Therapy offers opportunities to improve the physical and mental health of people living with mental illness.

Increased Neurotropic Threat from Burkholderia pseudomallei Strains with a B. mallei-like Variation in the bimA Motility Gene, Australia

These strains have heightened pathogenic potential for rapid dissemination to multiple tissues, including the central nervous system.

Neurologic melioidosis is a serious, potentially fatal form of Burkholderia pseudomallei infection. Recently, we reported that a subset of clinical isolates of B. pseudomallei from Australia have heightened virulence and potential for dissemination to the central nervous system. In this study, we demonstrate that this subset has a B. mallei–like sequence variation of the actin-based motility gene, bimA. Compared with B. pseudomallei isolates having typical bimA alleles, isolates that contain the B. mallei–like variation demonstrate increased persistence in phagocytic cells and increased virulence with rapid systemic dissemination and replication within multiple tissues, including the brain and spinal cord, in an experimental model. These findings highlight the implications of bimA variation on disease progression of B. pseudomallei infection and have considerable clinical and public health implications with respect to the degree of neurotropic threat posed to human health.

Chromosome microarray proficiency testing and analysis of quality metric data trends through an external quality assessment program for Australasian laboratories

Chromosome microarrays are an essential tool for investigation of copy number changes in children with congenital anomalies and intellectual deficit. Attempts to standardise microarray testing have focused on establishing technical and clinical quality criteria, however external quality assessment programs are still needed. We report on a microarray proficiency testing program for Australasian laboratories. Quality metrics evaluated included analytical accuracy, result interpretation, report completeness, and laboratory performance data: sample numbers, success and abnormality rate and reporting times. Between 2009 and 2014 nine samples were dispatched with variable results for analytical accuracy (30-100%), correct interpretation (32-96%), and report completeness (30-92%). Laboratory performance data (2007-2014) showed an overall mean success rate of 99.2% and abnormality rate of 23.6%. Reporting times decreased from >90 days to <30 days for normal results and from >102 days to <35 days for abnormal results. Data trends showed a positive correlation with improvement for all these quality metrics, however only 'report completeness' and reporting times reached statistical significance. Whether the overall improvement in laboratory performance was due to participation in this program, or from accumulated laboratory experience over time, is not clear. Either way, the outcome is likely to assist referring clinicians and improve patient care.

Are oral health-related self-efficacy, knowledge and fatalism indicators for non-toothbrush ownership in a homeless population?

AIM

To determine if the social cognitive theory (SCT)-constructs of oral health-related efficacy, knowledge and fatalism were indicators of non-toothbrush ownership in a metropolitan-based homeless population in Australia.

METHODS

Self-report data were collected from a convenience sample of 248 homeless participants located in Adelaide, Australia. Log binomial regression was used to estimate the strength of the association of the SCT constructs efficacy, knowledge and fatalism with the frequency of non-ownership of a toothbrush before and after adjusting for selected characteristics and associated factors.

RESULTS

Of the study population (aged 17-78 years, 79% male) just over one-fifth (21%) did not own a toothbrush. In an unadjusted model, low self-efficacy (PR = 1.18) and low knowledge (1.27) were indicators for non-toothbrush ownership. These relationships were attenuated by 5.2% and 3.2% respectively after adjusting for social determinants, health factors, substance use and dental service utilisation-related factors, but remained statistically significant in the final model.

CONCLUSIONS

Poor oral health-related self-efficacy and knowledge were both indicators for non-ownership of a toothbrush among a homeless population. This relationship held even after adjustment for relevant social and behavioural factors. Fatalism was not an indicator for non-toothbrush ownership in this population.

Development and psychometric validation of a Health Literacy in Dentistry scale (HeLD)

BACKGROUND

Oral health literacy is emerging as a new public health challenge and poor oral health literacy is increasingly seen as an important predictor of poor oral health outcomes. Within Indigenous populations, there may be benefits to research in using a culturally acceptable, internally consistent and valid instrument to assess oral health literacy. We translated a general health literacy measure, the Health Literacy Management (HeLM) scale to make a dentally relevant scale; Health Literacy in Dentistry (HeLD).

OBJECTIVE

This study describes the development and assessment of the reliability and validity of the HeLD in an Indigenous Australian population.

DESIGN AND METHODS

The 29 item HeLD scale assesses the components of oral health literacy. The reliability and validity of the seven HeLD subscales were evaluated in a convenience sample of 209 Indigenous Australians with mean age 35 years (range 17-81) and of which 139 were female.

RESULTS

The scale was supported by exploratory factor analysis and established seven distinct and internally consistent domains of oral health literacy: Communication, Access, Receptivity, Understanding, Utilisation, Support and Economic Barriers (Cronbach's alpha = 0.91). Discriminative ability was confirmed by HeLD associations with socio-demographic variables and self-reported health ratings in the expected direction. The convergent validity and predictive validity were confirmed by HeLD scores being significantly associated with toothbrush ownership, use of a toothbrush, time since last dental visit and knowledge of the effect of cordial on the teeth.

CONCLUSIONS

The HeLD appears to be an internally valid and reliable instrument and can be used for measuring oral health literacy among rural Indigenous Australian adults.

Residential carbon monoxide (CO) poisoning risks: correlates of observed CO alarm use in urban households

The authors conducted a household survey and observation to assess carbon monoxide (CO) knowledge and risks as well as prevalence of CO alarms in an urban community prior to the enactment of a mandatory ordinance requiring CO alarms in one U.S. city. From July to December 2009, household surveys and observations were completed in 603 residences. Participants were mostly African-American (61%), women (70%), 25-54 years in age (66%), and with a high school education or less (51%). Most homes visited contained CO-producing appliances, including gas stoves (86%), gas furnaces (82%), and gas water heaters (79%). Participants' overall mean percentage correct knowledge score was 57%. CO alarms were reported by 33% of participants and observed among 28% of households. Low rates of CO knowledge and CO alarm ownership, combined with high rates of CO-producing sources in homes, suggests the need for widespread campaigns to promote CO alarms. Recommendations are also made to integrate the lessons learned from the public health community's experience promoting smoke alarms.

A2A receptor antagonists do not induce dyskinesias in drug-naive or L-dopa sensitized rats

L-dopa, the precursor to dopamine, is currently the gold standard treatment for Parkinson's disease (PD). However, chronic exposure is associated with L-dopa-induced dyskinesias (LIDs), a serious side effect characterized by involuntary movements. Adenosine A2A receptor antagonists have been studied as a novel non-dopaminergic PD treatment. Because A2A receptor antagonists do not act on dopamine receptors, it has been hypothesized that they will not induce dyskinesias characteristic of L-dopa. To test this hypothesis in a rodent model, the A2A receptor antagonists SCH 412348 (3 mg/kg), vipadenant (10 mg/kg), caffeine (30 mg/kg), or istradefylline (3 mg/kg) were chronically (19-22 days) administered to Sprague Dawley rats, and dyskinetic behaviors were scored across this chronic dosing paradigm. Unlike L-dopa, there was no evidence of dyskinetic activity resulting from any of the four A2A receptor antagonists tested. When delivered to animals previously sensitized with L-dopa (6 mg/kg), SCH 412348, vipadenant, caffeine or istradefylline treatment produced no dyskinesias. When administered in combination with L-dopa (6 mg/kg), SCH 412348 (3 mg/kg) neither exacerbated nor prevented the induction of LIDs over the course of 19 days of treatment. Collectively, our data indicate that A2A receptor antagonists are likely to have a reduced dyskinetic liability relative to L-dopa but do not block dyskinesias when coadministered with L-dopa. Clinical studies are required to fully understand the dyskinesia profiles of A2A receptor antagonists.

Advocacy for health: revisiting the role of health promotion

ISSUE ADDRESSED

The importance of advocacy in protecting the population's health; and suggested strategies to advance an advocacy role.

DISCUSSION

This article explores the concept of health advocacy, discusses an example of successful health advocacy within Australia, and outlines and addresses some of the barriers to advocacy. It aims to encourage discussion on advocacy's potential to improve the public's health.

CONCLUSIONS

Many of the major successes of health promotion have been facilitated through the efforts of advocates. This article supports the proposition that advocacy is a fundamental instrument of health promotion practice and suggests strategies to apply these principles in practice.

A novel method of assessing quality of postgraduate psychiatry training: experiences from a large training programme

BACKGROUND

Most assessments of the quality of postgraduate training are based on anonymised questionnaires of trainees. We report a comprehensive assessment of the quality of training at a large postgraduate psychiatry training institute using non-anonymised face-to-face interviews with trainees and their trainers.

METHODS

Two consultant psychiatrists interviewed 99 trainees and 109 trainers. Scoring of interview responses was determined by using a pre-defined criteria. Additional comments were recorded as free text. Interviews covered 13 domains, including: Clinical, teaching, research and management opportunities, clinical environment, clinical supervision, adequacy of job description, absence of bullying and job satisfaction. Multiple interview domain scores were combined, generating a 'Combined' score for each post.

RESULTS

The interview response rate was 97% for trainers 88% for trainees. There was a significant correlation between trainee and trainer scores for the same interview domains (Pearson's r = 0.968, p< 0.001). Overall scores were significantly higher for specialist psychiatry posts as compared to general adult psychiatry posts (Two tailed t-test, p < 0.001, 95% CI: -0.398 to -0.132), and significantly higher for liaison psychiatry as compared to other specialist psychiatry posts (t-test: p = 0.038, 95% CI: -0.3901, -0.0118). Job satisfaction scores of year 1 to year 3 core trainees showed a significant increase with increasing seniority (Linear regression coefficient = 0.273, 95% CI: 0.033 to 0.513, ANOVA p= 0.026).

CONCLUSIONS

This in-depth examination of the quality of training on a large psychiatry training programme successfully elicited strengths and weakness of our programme. Such an interview scheme could be easily implemented in smaller schemes and may well provide important information to allow for targeted improvement of training. Additionally, trends in quality of training and job satisfaction amongst various psychiatric specialities were identified; specifically speciality posts and liaison posts in psychiatry were revealed to be the most popular with trainees.