A Residency Program Curriculum to Improve Health Care Transitions for Autistic Individuals

OBJECTIVES

Physical and mental health outcomes of autistic individuals deteriorate during transition to adulthood. The study aims to identify opportunities to improve physician knowledge in health-care transitions (HCT) for autistic individuals by understanding perceived versus experienced facilitators and barriers in overall HCT curriculum implementation in graduate medical education.

METHODS

Medicine-Pediatrics program directors participated in a Health Care Transition Residency Curriculum Collaborative Improvement Network and used an iterative process to develop and improve HCT curricula. Pre- and postcollaborative semistructured interviews were administered to program directors. The study occurred over 9 months (July 2018-February 2019). Recurring interview themes were analyzed utilizing Dedoose qualitative coding software and presented utilizing percentages and proportions.

RESULTS

Most program directors developed curricula in response to a gap in their current transition curricula. All program directors partially or completely met their goals during the collaborative. The most common types of curricular delivery were didactic (65%) and clinical experience-based (53%). Some tested unique delivery platforms, like the electronic medical record system (29%) and online modules (24%). Program directors often involved residents in the curricular development process and overwhelmingly (65%) felt this was a major facilitator. Competing priorities of faculty (71%) and of residents (53%) were the most common barriers.

CONCLUSIONS

Gaps in HCT curricula delivery were primarily attributed to suboptimal health care systems where training occurs, though existing clinical experiences and diverse learning modalities were successfully leveraged. Using a quality improvement framework and actively engaging resident trainees in curriculum development were successful strategies programs used in the development of HCT curricula.

What's new in psoriasis treatment? An analysis of systematic reviews published in 2015

This review provides a summary of key findings from 27 systematic reviews of 51 articles first published or indexed during 2015, focusing on the treatment of psoriasis and on precision medicine in psoriasis. The evidence supports weight-loss interventions by dieting and exercise for improvement in disease severity in overweight and obese patients with psoriasis. No significant increased risk of serious infections was reported for the biologic therapies adalimumab, etanercept and ustekinumab compared with appropriate comparators. Evidence could not provide reliable estimates of rare adverse events, emphasizing the need for large prospective registries. Polymorphisms in the tumour necrosis factor (TNF)-α gene may confer improved responses to TNF inhibitor (TNFI) therapy, but the studies to date lack power to detect a true association. From the limited available evidence, multidisciplinary management is both more effective and more satisfactory for patients with psoriasis and psoriatic arthritis than conventional consultations. This summary of reviews provides a succinct guide for clinicians and patients wishing to remain up to date with high-quality evidence for the treatment of psoriasis.

The immune risk phenotype is associated with IL-6 in the terminal decline stage: findings from the Swedish NONA immune longitudinal study of very late life functioning

In the present NONA immune longitudinal study, we further examine the previously identified T cell immune risk phenotype (IRP), relative inflammatory activity, morbidity and 2-year mortality in very old individuals >90 years. T-cell subsets as well as the inflammatory markers IL-6, IL-10, C-reactive protein, transthyretin and albumin were evaluated. IRP and low-grade inflammation predicted 57% of observed deaths and 97% of survival over 2 years, and was not significantly affected by individuals' health status, suggesting that the physiological ageing processes of T-cell immunosenescence and low-grade inflammation are of primary importance in late life survival. IRP non-survivors showed only a minor inflammatory activity at baseline, but had in contrast to survivors developed increased activity at follow-up. The results suggest a sequence of stages for IRP individuals that begin with acquisition of CMV infection in earlier life, followed by generation of CD8+CD28- cells to control persistent CMV infection and eventually the development of an IRP. Intriguingly, we also found that rare individuals moved out of the IRP category by a process of immune suppression, including increases in IL-6 and IL-10 and decreases in the number of CD3+CD8+CD28- cells. The further characterisation of these exceptional individuals may allow insight into remedial approaches for those who remain in the IRP category until death.

An immune risk phenotype, cognitive impairment, and survival in very late life: impact of allostatic load in Swedish octogenarian and nonagenarian humans

In the previous OCTO longitudinal study, we identified an immune risk phenotype (IRP) of high CD8 and low CD4 numbers and poor proliferative response. We also demonstrated that cognitive impairment constitutes a major predictor of nonsurvival. In the present NONA longitudinal study, we simultaneously examine in a model of allostatic load IRP and compromised cognition in 4-year survival in a population-based sample (n = 138, 86-94 years). Immune system measurements consisted of determinations of T-cell subsets, plasma interleukin 6 and cytomegalovirus and Epstein-Barr virus serology. Interleukin 2 responsiveness to concanavalin A, using data from the previous OCTO (octogenarians) immune study, hereafter OCTO immune, was also examined. Cognitive status was rated using a battery of neuropsychological tests. Logistic regression indicated that the IRP and cognitive impairment together predicted 58% of observed deaths. IRP was associated with late differentiated CD8+CD28-CD27- cells (p < .001), decreased interleukin 2 responsiveness (p < .05) and persistent viral infection (p < .01). Cognitive impairment was associated with increased plasma interleukin 6 (p < .001). IRP individuals with cognitive impairment were all deceased at the follow-up, indicating an allostatic overload.

Expansions of peripheral blood CD8 T-lymphocyte subpopulations and an association with cytomegalovirus seropositivity in the elderly: the Swedish NONA immune study

Results from a previous longitudinal study, the Swedish OCTO-Immune study, indicated that the combination of higher CD8 peripheral blood lymphocytes (PBLs), decreased CD4 PBLs, and poor proliferative response to mitogenic stimulation in very old humans were associated with an increased 2 year mortality. In follow up studies this combination of immune parameters was significantly associated with a CD4/CD8 ratio less than one and positive IgG serologic titers to cytomegalovirus (CMV). The present study, the Swedish NONA-Immune study, was an extension of that study, using a new sample of the very old. The results of this study confirmed the results of the previous study and extended the surface marker profile of the PBLs, indicating that the CD4/CD8 ratio change is associated with increased CD8 cells, decreased CD4 cells, and lymphocyte activation. The predominant phenotypes of the CD3+CD8+ cells were CD27-, CD28-, CD56+, and CD57+, CD45RA+, and double marked CD45RA+RO+. As in the OCTO study, the NONA-Immune data indicated that the changes are associated significantly with seropositive responses to CMV.

Racial and ethnic differences in drug treatment entry of injection drug users in Massachusetts

This article examines patterns of drug treatment entry among 28,000 adult injection drug users (IDUs), with special attention to racial and ethnic differences. The data analyzed originates from a statewide drug-treatment database covering four years. Through the use of logistic regression analysis, the study identified significant population differences between those who used detoxification only, those who used residential treatment and those who used methadone maintenance. Latino IDUs were approximately a third less likely than Caucasian IDUs to enter residential treatment and African American IDUs were half as likely as Caucasian IDUs to enter methadone maintenance treatment. This article discusses specific programmatic and research implications including the need to determine whether differential entry rates are due to access, client awareness, cultural, referral or other factors.

Cosmic dust analog simulation in a microgravity environment: the STARDUST program

We have undertaken a project called STARDUST which is a collaboration with Italian and American investigators. The goals of this program are to study the condensation and coagulation of refractory materials from the vapor and to study the properties of the resulting grains as analogs to cosmic dust particles. To reduce thermal convective currents and to develop valuable experience in designing an experiment for the Gas-Grain Simulation Facility aboard Space Station Freedom we have built and flown a new chamber to study these processes under periods of microgravity available on NASA's KC-135 Research Aircraft. Preliminary results from flights with magnesium and zinc are discussed.

Age-related changes in immune parameters in a very old population of Swedish people: a longitudinal study

This study used a longitudinal design to examine age-related changes in a well-defined sample of Swedish people ranging from 86 to 92 years of age at baseline. The longitudinal design encompassed three measurement occasions with 1 year intermeasurement intervals. The results were analyzed by multivariate analyses of variance (MANOVA), which is useful for comparing individuals over time. Healthy middle-aged subjects (39 years SD +/- 5.8) served as controls. The proliferative responses to Concanavalin A (Con A), a T-cell mitogen, indicated significant lower levels in responses of the old when the two groups were compared. The MANOVA revealed no significant change in mitogen responses over measurement occasions in the old sample as compared with the young. However, when cell types and lymphocyte subpopulations were examined, significant differences were found between the two age groups in many of these parameters and for some (lymphocyte percentages and numbers, CD3 numbers) the MANOVA indicated significant decreases over the measurement occasions in the very old. The results also consistently indicated significant intraindividual correlations in cell types, lymphocyte subpopulations, and mitogen responses over time.

The effects of group housing on the research use of the laboratory rabbit

This project evaluated the influence of group housing on common aspects of research use of female laboratory rabbits (Oryctolagus cuniculus). Eight rabbits housed individually in conventional cages were compared to a second group of 8 housed as a social group in a proportionately larger enclosure. The group housing method provided increased opportunities for exercise, social contact, and a more novel environment. As a function of housing style, the 2 experimental groups were compared on humoral and delayed hypersensitivity response, feed intake, growth rate, and selected physiological parameters that are considered to reflect stress in most species. Single and group housed rabbits did not significantly differ in physiological and immunological measurements, indicating that the practical research performance (immune response, stress level, growth rates etc.) of these rabbits was not significantly affected by group housing compared with the more traditional single housing. Analysis of group social behaviour indicated that the rabbits preferred small social groups, had preferences for microenvironments within the enclosure, and exhibited behaviours that are not possible when housed singly. Group housing appeared to be a successful method for enriching the environment of female rabbits and aspects of it should be considered in the approach to housing rabbits used in research.

An overview of the cosmic dust analogue material production in reduced gravity: the STARDUST experience

The formation, properties and chemical dynamics of microparticles are important in a wide variety of technical and scientific fields including synthesis of semiconductor crystals from the vapour, heterogeneous chemistry in the stratosphere and the formation of cosmic dust surrounding the stars. Gravitational effects on particle formation from vapors include gas convection and buoyancy and particle sedimentation. These processes can be significantly reduced by studying condensation and agglomeration of particles in microgravity. In addition, to accurately simulate particle formation near stars, which takes place under low gravity conditions, studies in microgravity are desired. We report here the STARDUST experience, a recent collaborative effort that brings together a successful American program of microgravity experiments on particle formation aboard NASA KC-135 Reduced Gravity Research Aircraft and several Italian research groups with expertise in microgravity research and astrophysical dust formation. The program goal is to study the formation and properties of high temperature particles and gases that are of interest in astrophysics and planetary science. To do so we are developing techniques that are generally applicable to study particle formation and properties, taking advantage of the microgravity environment to allow accurate control of system parameters.

Age-related changes in release of soluble interleukin-2 receptor by murine lymphocytes

The purpose of this study was to investigate whether the presence of soluble interleukin-2 receptors (sIL-2R) in the supernatants of activated splenocytes correlates with age progression in C57BL/6 mice. In addition, the relationship between IL-2R cell surface expression and release of sIL-2R was examined. The results indicated splenocytes from young (3-4-month-old) mice release higher levels of sIL-2R than those from intermediate (18-19-month-old) or old (24-25-month-old) mice. While there was no statistical difference between sIL-2R levels in intermediate and old mice in this study, the old mice did have a slightly higher release of sIL-2R than the intermediate mice. There was a correlation between IL-2R cell surface expression and the level of sIL-2R in the young and the intermediate age groups. In old mice there was no correlation between these two parameters.

Characteristics of Yorkshire swine natural killer cells

The present study examined the properties of NK activity in Yorkshire swine. The results support other porcine studies which indicate the swine NK system has both similarities and differences to this system in other species. Profiles of NK activity indicated swine NK cells are highly reactive against the YAC-1 lymphoma, the K-562 myeloid leukemia, the P-815 mastocytoma, and the TU-5 virally transformed fibroblast. In contrast, the MOLT-4 and SB leukemias are NK resistant. Kinetic studies indicated that in Yorkshire swine, NK lysis begins 6 h after mixing effectors and targets. The kinetics of the lytic reaction differ both from other breeds of swine and from other species, where cytotoxicity is readily measured in 4-h assays. The delayed lysis was not due to delayed target cell recognition, because Yorkshire swine NK cells are rapidly bound to tumor targets. The delayed lysis seems to be due to a refractoriness in the NK lytic mechanism. This delay may relate to the morphologic finding that the target-binding cell in Yorkshire swine appeared quite different from the large granular lymphocyte (LGL) reported as the NK effector in humans and rodents. Indeed, in light microscopic studies the typical tumor-binding cell in Yorkshire swine is a small, apparently nongranular, lymphocyte. Analysis of NK activity at the single cell level was performed with single effector-tumor conjugates immobilized in agarose. Generally, lysis by target binders paralleled sensitivity to lysis in 51Cr release tests, indicating lysis in agarose may be used as an NK index in swine. Like other species, swine NK cells were found to be nonadherent lymphocytes with a characteristic tissue distribution. Peripheral blood and spleen had the highest levels of NK activity. Lymph node cells displayed a small amount of NK activity which was limited to the YAC-1 target, while thymocytes showed no appreciable NK activity against any of the cell lines tested.

Influence of sex differences and knee joint position on electrical stimulation-modulated strength increases

This study examined the influence of sex differences and knee joint position on the effectiveness of isometric electrical stimulation in improving isometric and isokinetic strength. Twenty-seven females and 28 male subjects were assigned to either a control group (C) that received no electrical stimulation, to an experimental group that received stimulation of the quadriceps with the knee flexed at 65 degrees (EF), or to an experimental group that received electrical stimulation of the quadriceps with the knee fully extended (EE). Experimental subjects received 15 min of electrical stimulation 3 times/wk for a total of 6 wk. Before and after the study, knee extension strength was measured with a Cybex II, isometrically at 65 degrees of knee flexion and isokinetically at 30 degrees . s-1, 60 degrees . s-1, 90 degrees . s-1, and 120 degrees s-1. Multivariate analysis of covariance, using the pretests as the covariate, revealed no sex differences in responsiveness to electrical stimulation. EF was superior to EE at 30 degrees . s-1 and 120 degrees . s-1 in females and at 120 degrees . s-1 in males (P less than 0.05). Male and female EF was superior to C in all tests. EE was higher than C at isometric, 30 degrees . s-1, 90 degrees . s-1, and 120 degrees . s-1 in females and at isometric and 30 degrees . s-1 in males. These data suggest that electrical stimulation at the quadriceps can increase isometric and isokinetic strength and may be more effective in improving isokinetic strength if the knee is flexed during treatment.

Making hospital preparation child-centered (with a little help from Emily)

Helping youg children learn about the hospital shoould, ideally, involve a multifaceted approach that utilizes tools appropriate to the child's age and needs. The hospital preparation process at Alberta Children's Hospital that has attempted to achieve this end through the coordinated efforts of the Recreation/Child Life and Nursing departments is discussed. Our preparation process consists of several phases, commencing prior to admission and carrying right through until discharge, with the "thread" that draws it all together being a whimsical kitten named Emily.

Platelet dynamics in chronic liver disease with special reference to the role of the spleen

In all of 12 patients with chronic liver disease, whose platelet dynamics were investigated by the 51Cr-labelling technique in association with surface counting, platelet survival was reduced and in 11 the splenic platelet pool was increased. Surface counting showed high initial spleen liver ratios in eight patients, and in four there was evidence of progressive destruction of platelets in the spleen. In one patient, subsequently shown to have a hepatoma, progressive accumulation of platelets was noted at the tumour site.