Training Among Noncustodial Health Care Workers Caring for Patients Experiencing Incarceration: A Preliminary Investigation

People experiencing incarceration in the United States receive much of their health care outside of custodial settings. Optimizing care in this setting requires further understanding of the training and experiences of noncustodial health care workers. We conducted a cross-sectional, exploratory survey of health care workers at a single academic institution to assess their training and experiences related to caring for this patient population. Of 333 respondents, 94.1% had cared for patients experiencing incarceration but only 22.5% had received any formal training, with 94.6% somewhat or very interested in further training. Common challenges included lack of privacy, difficulty obtaining patient history or completing an examination, and patient distress. Health care workers frequently experience challenges and report strong interest in further training to address knowledge gaps, and further detailed investigation is needed.

Intensive Continuous Positive Airway Pressure Adherence Program During Stroke Rehabilitation

Background and Purpose- Continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea may improve stroke recovery, but adherence is poor. We assessed the effectiveness of an intensive CPAP adherence program during and after inpatient stroke rehabilitation on 3-month adherence and stroke recovery. Methods- In a single-arm study, 90 stroke rehabilitation patients were enrolled into an intensive CPAP adherence program. CPAP was continued after a run-in among qualifying patients with evidence of obstructive sleep apnea. The primary outcome was CPAP adherence, defined as ≥4 hours of use on ≥70% of days, over 3 months. Results- A total of 62 patients qualified for continued CPAP and 52 of these were willing to continue CPAP after discharge from rehabilitation. At 3 months, the average daily CPAP use was 4.7 hours (SD 2.6), and 32/52 (62%) patients were adherent. Factors significantly associated with adherence included more severe stroke, aphasia, and white race. Compared with nonadherent patients, adherent patients experienced greater improvements in the cognitive component of the Functional Independence Measure ( P=0.02) and in the National Institutes of Health Stroke Scale ( P=0.03). Conclusions- This intensive CPAP adherence program initiated during stroke rehabilitation can lead to CPAP adherence in the majority of patients with evidence of obstructive sleep apnea, including those with more severe stroke and aphasia, and may promote recovery. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02809430.

Abstract TP382: Novel and Modifiable Factors Associated With Adherence to Cpap Therapy During Acute Stroke Rehabilitation: A Qualitative Analysis

Background: Continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea (OSA) may improve stroke recovery but prior studies have been limited by poor adherence. In a single-arm study of stroke rehabilitation patients treated with CPAP, we evaluated environmental, behavioral and social factors associated with CPAP adherence.

Methods: As part of an intensive CPAP adherence protocol, stroke rehabilitation patients were assessed for OSA based on CPAP device download. Qualifying patients underwent motivational interviewing (MI) sessions to set goals and address barriers for CPAP use. Patients who planned to continue CPAP after rehabilitation unit discharge were asked after 3-months to detail facilitators or barriers to continued CPAP use. We conducted a thematic analysis of the MI and 3-month interview notes, with four authors each coding modifiable and less modifiable barriers and facilitators.

Results: Among 52 subjects who planned to continue CPAP over 3-months, 32 (62%) were adherent, defined as ≥ 4 hours on ≥ 70% of days. Adherent patients were less likely to complain of claustrophobia than non-adherent patients (13% vs. 42%, p =0.02). Facilitators for adherence were improved sleep quality and daytime function, self-efficacy with CPAP, social support, and positive expectations of treatment benefit. Common modifiable barriers included discomfort using a new health technology, common CPAP side effects and anxiety. Several patients described more complex and less modifiable barriers such as social stressors, sleep disturbance, lack of social support and competing health issues.

Conclusions: An intensive CPAP adherence protocol with MI sessions during rehabilitation yielded a high rate of adherence even outside of the supportive inpatient environment. Adherence programs for CPAP after stroke should focus on interventions to address modifiable barriers, including early desensitization to improve anxiety or claustrophobia and continued education or training to address perceived self-efficacy and importance of CPAP therapy. Future studies should assess the effectiveness of MI to identify factors associated with CPAP adherence and to design interventions to improve long-term adherence by modifying these factors.

Aiming to Miss a Moving Target: Bromo and Extra Terminal Domain (BET) Selectivity in Constrained ATAD2 Inhibitors

ATAD2 is a cancer-associated protein whose bromodomain has been described as among the least druggable of its class. In our recent disclosure of the first chemical probe against this bromodomain, GSK8814 (6), we described the use of a conformationally constrained methoxy piperidine to gain selectivity over the BET bromodomains. Here we describe an orthogonal conformational restriction strategy of the piperidine ring to give potent and selective tropane inhibitors and show structural insights into why this was more challenging than expected. Greater understanding of why different rational approaches succeeded or failed should help in the future design of selectivity in the bromodomain family.

Abstract TMP45: An Intensive Multidisciplinary Protocol for Improving Adherence to CPAP Therapy During Inpatient Rehabilitation May Improve Recovery in Stroke Patients

Introduction: Obstructive sleep apnea (OSA) is associated with worse outcome after stroke. Treatment with continuous positive airway pressure (CPAP) may improve recovery after stroke but has been limited by poor adherence.

Methods: In a single-arm ongoing study, adults with stroke underwent an intensive CPAP adherence protocol during inpatient rehabilitation, including motivational interviewing and help with CPAP by nurses and respiratory therapists. A 3-night run-in period of auto-titrating CPAP was used to test for tolerance and to diagnose OSA, based upon the apnea-hypopnea index and flow resistance. Qualifying patients were asked to continue CPAP for 3 months. The outcomes included CPAP adherence, defined as ≥ 4 hours of use on ≥ 70% of nights, and stroke recovery, measured by change in NIH Stroke scale (NIHSS) and Functional Independence Measure (FIM) over 3 months.

Results: During the run-in, 39 of 60 (65%) patients had presumed OSA, 5 (8%) had no evidence of OSA, 4 (7%) had evidence of central sleep apnea, and 12 (20%) were intolerant of CPAP. Among the 34 of 39 patients who chose to continue CPAP after the run-in, the median use per night was 5.3 hours (IQR 4.1, 6.0) with 56% (n=19) adherent during rehabilitation. The median CPAP use per night for the 22 who completed the study was 5.1 hours (IQR 2.5, 6.4) with 54% (n=12) adherent over the 3-month period. Unadjusted for baseline factors, there was a significant change in the NIHSS in adherent patients (n=10) vs. non-adherent patients (n=10) [5 (SD 3) vs. 2 (SD 2), p =0.02]. Comparing adherent (n=7) to non-adherent patients (n=5), the change for total FIM trended towards significant [42 (SD 18) vs. 30 (SD 11), p =0.20] and the change for cognitive component of the FIM was significant [10 (SD 7) vs. 2 (SD 3), p =0.05].

Conclusion: After an intensive adherence intervention, over half of stroke patients with presumed OSA and CPAP tolerance were adherent over 3 months. CPAP adherent patients had greater improvement in NIHSS and the cognitive component of the FIM, although the associations may be confounded by patients’ characteristics influencing both adherence and outcomes. Future studies are needed to evaluate in a randomized trial if the intensive intervention will lead to long-term CPAP adherence and improved stroke recovery.

Whole genome sequencing reveals a 7 base-pair deletion in DMD exon 42 in a dog with muscular dystrophy

Dystrophin is a key cytoskeletal protein coded by the Duchenne muscular dystrophy (DMD) gene located on the X-chromosome. Truncating mutations in the DMD gene cause loss of dystrophin and the classical DMD clinical syndrome. Spontaneous DMD gene mutations and associated phenotypes occur in several other species. The mdx mouse model and the golden retriever muscular dystrophy (GRMD) canine model have been used extensively to study DMD disease pathogenesis and show efficacy and side effects of putative treatments. Certain DMD gene mutations in high-risk, the so-called hot spot areas can be particularly helpful in modeling molecular therapies. Identification of specific mutations has been greatly enhanced by new genomic methods. Whole genome, next generation sequencing (WGS) has been recently used to define DMD patient mutations, but has not been used in dystrophic dogs. A dystrophin-deficient Cavalier King Charles Spaniel (CKCS) dog was evaluated at the functional, histopathological, biochemical, and molecular level. The affected dog's phenotype was compared to the previously reported canine dystrophinopathies. WGS was then used to detect a 7 base pair deletion in DMD exon 42 (c.6051-6057delTCTCAAT mRNA), predicting a frameshift in gene transcription and truncation of dystrophin protein translation. The deletion was confirmed with conventional PCR and Sanger sequencing. This mutation is in a secondary DMD gene hotspot area distinct from the one identified earlier at the 5' donor splice site of intron 50 in the CKCS breed.

Structure-Based Optimization of Naphthyridones into Potent ATAD2 Bromodomain Inhibitors

ATAD2 is a bromodomain-containing protein whose overexpression is linked to poor outcomes in a number of different cancer types. To date, no potent and selective inhibitors of the bromodomain have been reported. This article describes the structure-based optimization of a series of naphthyridones from micromolar leads with no selectivity over the BET bromodomains to inhibitors with sub-100 nM ATAD2 potency and 100-fold BET selectivity.

Wide-field four-channel fluorescence imager for biological applications

A wide-field four-channel fluorescence imager has been developed. The instrument uses four expanded laser beams to image a large section (6 mm x 9 mm). An object can be sequentially illuminated with any combination of 408-, 532-, 658-, and 784-nm lasers for arbitrary (down to 1 ms) exposure times for each laser. Just two notch filters block scattered light from all four lasers. The design approach described here offers great flexibility in treatment of objects, very good sensitivity, and a wide field of view at low cost. There appears to be no commercial instrument capable of simultaneous fluorescence imaging of a wide field of view with four-laser excitation. Some possible applications are following events such as flow and mixing in microchannel systems, the transmission of biological signals across a culture, and following simulations of biological membrane diffusion. It can also be used in DNA sequencing by synthesis to follow the progress of the photolytic removal of dye and terminator. Without utilizing its time resolution, it can be used to obtain four independent images of a single tissue section stained with four targeting agents, with each coupled to a different dye matching one of the lasers.

Status of carotid endarterectomy

The randomized clinical trial has been brought to bear on the indications and the search for benefit for the surgical procedure of carotid endarterectomy. Progress has been made and some answers are available. It is not too optimistic to state that in a few years time, we will be able to state with some degree of finality, which patients with symptomatic disease will benefit from carotid endarterectomy, which ones will be better treated with medical therapy alone, and whether or not there is a group of patients, despite being asymptomatic, who should be advised to have this procedure.

Discounting surgical benefits. Enucleation versus resection of the prostate

This manuscript introduces and demonstrates a modification of the popular cost-effectiveness methodology. Because arbitrarily selected discount rates for future health effects can radically change the cost-effect ratio, the determinants of the ratio--differences in the present values of effects and costs-are examined for a wide range of discount rates. Treatment selection then follows directly from explicit judgments about expected patient longevity and appropriate combinations of cost and effect discount rates. The decision to select resection or enucleation of a benign prostatic hypertrophy is developed with data from a small number of clinical patients from Washington University.

Squamous cell carcinoma of the body of the uterus

A case of primary squamous cell carcinoma of the body of the uterus is reported. The number of authentic cases of this tumour which meet the rigid criteria referred to is extremely small. The histological findings are described in detail and some aetiological considerations are mentioned briefly. Certain special aspects of the diagnosis are discussed.