Undermining the Translational Potential of Clinical Research with Adolescents and Young Adults: Differential Enrollment in Randomized Clinical Trials During COVID-19

BACKGROUND

COVID-19 stay-at-home orders and research restrictions halted recruitment and follow-up of clinical research patients. While clinical research has resumed, it is an open question whether research participation has returned to levels similar to those before COVID-19.

METHODS

We utilized data from the TECH-PN (NCT# NCT03828994) study, a single-center RCT enrolling 13-25-year-olds with mild-moderate pelvic inflammatory disease (PID) receiving ambulatory care. We examined enrollment patterns before COVID-19 and during/after COVID-19 among those assessed for eligibility by estimating the average rate of recruitment visits for each period. We focused on this monthly rate by pandemic status, the length of stay (LOS) by pandemic status, as well as the relationship between the LOS and patient demographics. Descriptive analyses were conducted, including Student's t-test to compare rates between time periods and a Chi-square test to compare the proportion refusing enrollment.

RESULTS

The monthly enrollment rate during/post-pandemic was significantly lower than before COVID-19 (4.8 per month compared to 7.4 per month, p < 0.001). However, eligible participants' age, race, and insurance type were similar pre- and during/post-pandemic. Among eligible patients, LOS for receiving PID care was slightly increased, from a median of 5.4 hours to 6.4 hours (p = 0.650), and the rate of refusal to participate among those eligible was similar (23% versus 27%, p = 0.362). There was a similar number of ineligible patients due to inpatient admissions during both periods.

CONCLUSION

COVID-19 pandemic restrictions negatively impacted recruitment into this RCT. Enrollment differences may reflect ongoing perceptions of restrictions in care access or a hesitancy to use health services. More research is needed to stabilize access to ambulatory STI/PID care and access to clinical trials.

Fluctuation Relations to Calculate Protein Redox Potentials from Molecular Dynamics Simulations

The tunable design of protein redox potentials promises to open a range of applications in biotechnology and catalysis. Here, we introduce a method to calculate redox potential changes by combining fluctuation relations with molecular dynamics simulations. It involves the simulation of reduced and oxidized states, followed by the instantaneous conversion between them. Energy differences introduced by the perturbations are obtained using the Kubo-Onsager approach. Using a detailed fluctuation relation coupled with Bayesian inference, these are postprocessed into estimates for the redox potentials in an efficient manner. This new method, denoted MD + CB, is tested on a de novo four-helix bundle heme protein (the m4D2 "maquette") and five designed mutants, including some mutants characterized experimentally in this work. The MD + CB approach is found to perform reliably, giving redox potential shifts with reasonably good correlation (0.85) to the experimental values for the mutants. The MD + CB approach also compares well with redox potential shift predictions using a continuum electrostatic method. The estimation method employed within the MD + CB approach is straightforwardly transferable to standard equilibrium MD simulations and holds promise for redox protein engineering and design applications.

Chemical bonding of HF, HCl, and H 2 O onto YF 3 surfaces: Quantification by first principles

The surfaces of waimirite β- YF 3 have been studied for their fluorine and chlorine versus water affinity. Bonding patterns of HF, HCl, and H 2 O chemically adsorbed onto surfaces of (010), (100), (011), and (101) have been quantified by density functional theory applying energy decomposition analysis. We found that the adsorption of H 2 O is dominated by about 65% of electrostatics, which causes a low surface sensitivity and weak interactions. On the contrary, the adsorptions of HF and HCl are driven by strong hydrogen bonds resulting in a highly surface-dependent ratio of 30-60% electrostatic versus orbital contribution. Among the stoichiometric surfaces, the shortest and strongest hydrogen bonds and consequently most covalent bonding patterns are found within YF 3 · HCl. However, when including the preparation energy, each surface favors the adsorption of HF over HCl, which reproduces the higher affinity of yttrium towards fluoride over chloride, previously known for solutions, also for the solid state.

Correction: Anders et al. First Principle Surface Analysis of YF3 and Isostructural HoF3. Materials 2022, 15, 6048

In the original publication [...].

Practical Recommendations for Prehospital Selection of Pediatric Pelvic Circumferential Compression Devices

INTRODUCTION

Although the instances of Special Operations Forces (SOF) medical providers treating pediatric pelvic fractures are rare, such fractures are notable injuries in terror attacks and are at high risk for morbidity and mortality for the patient as well as stress for the provider. Presently, guidelines for pediatric-sized pelvic stabilization device application are limited to measured pelvic circumference. This study aims to inform more practical sizing guidelines.

METHODS

Subjects aged 1 year to 14 years were enrolled. Subject height, weight, pelvic circumference, and fit on the Broselow Pediatric Emergency Tape® (Armstrong Medical Industries), fit with the Pediatric PelvicBinder® (PelvicBinder), and fit with the small SAM Pelvic Sling® (SAM® Medical) were collected. The primary outcome was the proportion of subjects fitting each device.

RESULTS

Sixty-five subjects were recruited; median age was 5 years (interquartile range, 1-8 years); 40 (62%) subjects were male. Ninety-one percent of subjects fit within the scale of the Broselow Tape (height <143-cm). One hundred percent of subjects with a height <143-cm had an appropriate fit with the Pediatric PelvicBinder (95% confidence level [CI], 91.8-100%), while 91.7% of subjects with a height >143-cm fit the SAM Pelvic Sling (95%CI, 61.5-99.8%).

CONCLUSIONS

Providers should attempt to fit the Pediatric PelvicBinder for children >1 year old with suspected unstable pelvic fracture who fall on the Broselow Tape (<143-cm). The small SAM Pelvic Sling should be used for those taller than 143-cm.

The Effect of Documenting Patient Weight in Kilograms on Pediatric Medication Dosing Errors in Emergency Medical Services

Objectives: Up to 40% of children who receive a medication from emergency medical services (EMS) are subject to a dosing error. One of the reasons for this is difficulties adjusting dosages for weight. Converting weights from pounds to kilograms complicates this further. This is the rationale for the National EMS Quality Alliance measure Pediatrics-03b, which measures the proportion of children with a weight documented in kilograms. However, there is little evidence that this practice is associated with lower rates of dosing errors. Therefore, our objective was to determine whether EMS documentation of weight in kilograms was associated with a lower rate of pediatric medication dosing errors.Methods: We conducted a retrospective cross-sectional study of children 0-14 y/o in the 2016-17 electronic Maryland Emergency Medical Services Data System that received a weight-based medication. Using validated age-based formulas, we assigned a weight to patients without one documented. Doses were classified as errors and severe errors if they deviated from the state protocol by >20% or >50%, respectively. We compared the dosage errors in the two groups and completed secondary analyses for specific medications and age groups.Results: We identified 3,618 cases of medication administration, 53% of which had a documented weight. Patients with a documented weight had a significantly lower overall dose error rate than those without (22 vs. 26%, p<.05). A sensitivity analysis in which we assigned a weight to those patients with a weight recorded did not significantly change this result. Sub-analyses by individual medication showed that only epinephrine (34 vs. 56%, p<.05) and fentanyl (10 vs. 31%, p <.05) had significantly lower dosing error rates for patients with a documented weight. Infants were the only age group where documenting a weight was associated with a lower dosing error rate (33 vs. 53% p<.05).Conclusion: Our findings suggest that documenting a weight in kilograms is associated with a small but significantly lower rate of pediatric dosing errors by EMS. Documenting a weight in kilograms appears particularly important for specific medications and patient age groups. Additional strategies (including age-based standardized dosing) may be needed to further reduce pediatric dosing errors by EMS.

Serious Bacterial Infections in Young Febrile Infants With Positive Urinalysis Results

It is unknown whether febrile infants 29 to 60 days old with positive urinalysis results require routine lumbar punctures for evaluation of bacterial meningitis.

OBJECTIVE

To determine the prevalence of bacteremia and/or bacterial meningitis in febrile infants ≤60 days of age with positive urinalysis (UA) results.

METHODS

Secondary analysis of a prospective observational study of noncritical febrile infants ≤60 days between 2011 and 2019 conducted in the Pediatric Emergency Care Applied Research Network emergency departments. Participants had temperatures ≥38°C and were evaluated with blood cultures and had UAs available for analysis. We report the prevalence of bacteremia and bacterial meningitis in those with and without positive UA results.

RESULTS

Among 7180 infants, 1090 (15.2%) had positive UA results. The risk of bacteremia was higher in those with positive versus negative UA results (63/1090 [5.8%] vs 69/6090 [1.1%], difference 4.7% [3.3% to 6.1%]). There was no difference in the prevalence of bacterial meningitis in infants ≤28 days of age with positive versus negative UA results (∼1% in both groups). However, among 697 infants aged 29 to 60 days with positive UA results, there were no cases of bacterial meningitis in comparison to 9 of 4153 with negative UA results (0.2%, difference -0.2% [-0.4% to -0.1%]). In addition, there were no cases of bacteremia and/or bacterial meningitis in the 148 infants ≤60 days of age with positive UA results who had the Pediatric Emergency Care Applied Research Network low-risk blood thresholds of absolute neutrophil count <4 × 103 cells/mm3 and procalcitonin <0.5 ng/mL.

CONCLUSIONS

Among noncritical febrile infants ≤60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making.

First Principle Surface Analysis of YF3 and Isostructural HoF3

The trifluorides of the two high field strength elements yttrium and holmium are studied by periodic density functional theory. As a lanthanide, holmium also belongs to the group of rare earth elements (REE). Due to their equivalent geochemical behavior, both elements form a geochemical twin pair and consequently, yttrium is generally associated with the REE as REE+Y. Interestingly, it has been found that DFT/DFT+U describe bulk HoF₃ best, when the 4f-electrons are excluded from the valence region. An extensive surface stability analysis of YF₃ (PBE) and HoF₃ (PBE+Ud/3 eV/4f-in-core) using two-dimensional surface models (slabs) is performed. All seven low-lying Miller indices surfaces are considered with all possible stoichiometric or substoichiometric terminations with a maximal fluorine-deficit of two. This leads to a scope of 24 terminations per compound. The resulting Wulff plots consists of seven surfaces with 5-26% abundance for YF₃ and six surfaces with 6-34% for HoF₃. The stoichiometric (010) surface is dominating in both compounds. However, subtle differences have been found between these two geochemical twins.

Identification of factors associated with return of spontaneous circulation after pediatric out-of-hospital cardiac arrest using natural language processing

Introduction: Prior studies examining prehospital characteristics related to return of spontaneous circulation (ROSC) in pediatric out-of-hospital cardiac arrest (OHCA) are limited to structured data. Natural language processing (NLP) could identify new factors from unstructured data using free-text narratives. The purpose of this study was to use NLP to examine EMS clinician free-text narratives for characteristics associated with prehospital ROSC in pediatric OHCA.Methods: This was a retrospective analysis of patients ages 0-17 with OHCA in 2019 from the ESO Data Collaborative. We performed an exploratory analysis of EMS narratives using NLP with an a priori token library. We then constructed biostatistical and machine learning models and compared their performance in predicting ROSC.Results: There were 1,726 included EMS encounters for pediatric OHCA; 60% were male patients, and the median age was 1 year (IQR 0-9). Most cardiac arrest events (61.3%) were unwitnessed, 87.3% were identified as having medical causes, and 5.9% had initial shockable rhythms. Prehospital ROSC was achieved in 23.1%. Words most positively correlated with ROSC were "ROSC" (r = 0.42), "pulse" (r = 0.29), "drowning" (r = 0.13), and "PEA" (r = 0.12). Words negatively correlated with ROSC included "asystole" (r = -0.25), "lividity" (r = -0.14), and "cold" (r = -0.14). The terms 'asystole,' 'pulse', 'no breathing', 'PEA', and 'dry' had the greatest difference in frequency of appearance between encounters with and without ROSC (p < 0.05). The best-performing model for predicting prehospital ROSC was logistic regression with random oversampling using free-text data only (area under the receiver operating characteristic curve 0.92).Conclusions: EMS clinician free-text narratives reveal additional characteristics associated with prehospital ROSC in pediatric OHCA. Incorporating those terms into machine learning models of prehospital ROSC improves predictive ability. Therefore, NLP holds promise as a tool for use in predictive models with the goal to increase evidence-based management of pediatric OHCA.

Weak and Ultrastrong Coupling Limits of the Quantum Mean Force Gibbs State

The Gibbs state is widely taken to be the equilibrium state of a system in contact with an environment at temperature T. However, non-negligible interactions between system and environment can give rise to an altered state. Here, we derive general expressions for this mean force Gibbs state, valid for any system that interacts with a bosonic reservoir. First, we derive the state in the weak coupling limit and find that, in general, it maintains coherences with respect to the bare system Hamiltonian. Second, we develop a new expansion method suited to investigate the ultrastrong coupling regime. This allows us to derive the explicit form for the mean force Gibbs state, and we find that it becomes diagonal in the basis set by the system-reservoir interaction instead of the system Hamiltonian. Several examples are discussed including a single qubit, a three-level V-system, and two coupled qubits all interacting with bosonic reservoirs. The results shed light on the presence of coherences in the strong coupling regime, and provide key tools for nanoscale thermodynamics investigations.

Applying a set of termination of resuscitation criteria to paediatric out-of-hospital cardiac arrest

OBJECTIVE

Prehospital Termination of Resuscitation (TOR) protocols for adults can reduce the number of futile transports of patients in cardiac arrest, yet similar protocols are not widely available for paediatric out-of-hospital cardiac arrest (POHCA). The objective of this study was to apply a set of criteria for paediatric TOR (pTOR) from the Maryland Institute for Emergency Medical Services Systems (MIEMSS) to a large national cohort and determine its association with return of spontaneous circulation (ROSC) after POHCA.

METHODS

We identified patients ages 0-17 treated by Emergency Medical Services (EMS) with cardiac arrest in 2019 from the ESO dataset and and applied the applicable pTOR certeria for medical or traumatic arrests. We calculated predictive test characteristics for the outcome of prehospital ROSC, stratified by medical and traumatic cause of arrest.

RESULTS

We analyzed records for 1595 POHCA patients. Eighty-eight percent (n = 1395) were classified as medical. ROSC rates were 23% among medical POHCA and 27% among traumatic POHCA. The medical criteria correctly classified >99% (322/323) of patients who achieved ROSC as ineligible for TOR. The trauma criteria correctly classified 93% (50/54) of patients with ROSC as ineligible for TOR. Of the five misclassified patients, three were involved in drowning incidents.

CONCLUSIONS

The Maryland pTOR criteria identified eligible patients who did not achieve prehospital ROSC, while reliably excluding those who did achieve prehospital ROSC. As most misclassified patients were victims of drowning, we recommend considering the exclusion of drowning patients from future pTOR guidelines. Further studies are needed to evaluate the long-term survival and neurologic outcome of patients misclassified by pTOR criteria.

Using Innovation to Address Adolescent and Young Adult Health Disparities in Pelvic Inflammatory Disease: Design of the Technology Enhanced Community Health Precision Nursing (TECH-PN) Trial

New approaches to pelvic inflammatory disease (PID) care among adolescents and young adults (AYAs) that optimize self-care and personalize treatment are warranted to address age and racial-ethnic PID-related health disparities. Here we describe the 13-month preliminary feasibility and acceptability outcomes of recruitment, retention, and intervention delivery for Technology Enhanced Community Health Precision Nursing (TECH-PN) randomized controlled trial. Urban AYAs 13-25 years assigned female sex at birth with acute mild-moderate PID provided baseline and follow-up interview data and vaginal specimens for sexually transmitted infection (STI), cytokine, and microbiota assessment. All participants received medications and text-messaging support. Participants were block randomized to either control or intervention. Control participants received 1 community nursing visit with self-management for interim care per national guidelines. Intervention participants received unlimited precision care services driven by interim STI and macrolide resistance testing results by an advanced practice provider. In the first 13 months, 75.2% patients were eligible, and 76.1% of eligible patients enrolled. Of the participants, 94% completed the intervention and 96%, 91%, and 89%, respectively, completed their 14-, 30-, and 90-day visits. Baseline laboratory results revealed infection rates that were highest for Mycoplasma genitalium (45%) followed by Chlamydia trachomatis (31%). Preliminary enrollment, STI, intervention delivery, and retention data demonstrate the feasibility and acceptability of the TECH-PN intervention and support rationale for precision care for PID among urban AYAs. ClinicalTrials.gov Identifier. NCT03828994.

Clearance of Mycoplasma genitalium and Trichomonas vaginalis Among Adolescents and Young Adults With Pelvic Inflammatory Disease: Results From the Tech-N Study

Current pelvic inflammatory disease (PID) treatment effectively treats Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT). However, coverage may be inadequate for Mycoplasma genitalium (MG)/Trichomonas vaginalis (TV) infections. We compared the longitudinal MG and TV outcomes with NG/CT outcomes for women enrolled in a longitudinal randomized controlled trial to optimize outcomes after PID. The prevalences of CT and NG were lower at 30- and 90-day follow-up compared with the prevalence at the time of diagnosis. No significant difference was observed for MG (odds ratio, 0.95; 0.86-1.04; P = 0.265) and TV (odds ratio, 0.89; 0.75-1.04; P = 0.146) over time for both treatment groups, showing that persistence and/or reinfection with MG and TV occurs more frequently than with CT or NG after treatment of PID using current national treatment guidelines.

High-Throughput Detection and Characterization of Antimicrobial Resistant Enterococcus sp. Isolates from GI Tracts of European Starlings Visiting Concentrated Animal Feeding Operations

Antimicrobial resistant enteric bacteria can easily contaminate the environment and other vehicles through the deposition of human and animal feces. In turn, humans can be exposed to these antimicrobial resistant (AMR) bacteria through contaminated food products and/or contaminated drinking water. As wildlife are firmly established as reservoirs of AMR bacteria and serve as potential vectors in the constant spread of AMR, limiting contact between wildlife and livestock and effective tracking of AMR bacteria can help minimize AMR dissemination to humans through contaminated food and water. Enterococcus spp., which are known opportunistic pathogens, constantly found in gastrointestinal tracts of mammalian and avian species, swiftly evolve and cultivate AMR genotypes and phenotypes, which they easily distribute to other bacteria, including several major bacterial pathogens. In this study, we evaluated the use of high throughput detection and characterization of enterococci from wildlife [European starlings (Sturnus vulgaris)] by matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) following culture-based isolation. MALDI-TOF MS successfully identified 658 Enterococcus spp. isolates out of 718 presumptive isolates collected from gastrointestinal tracts of European starlings, which were captured near livestock operations in Colorado, Iowa, Kansas, Missouri, and Texas; antimicrobial susceptibility testing was then performed using 13 clinically significant antibiotics.

MR to go

In this paper, we provide a review of the recent advances in miniaturizing nuclear magnetic resonance (NMR) and electron paramagnetic resonance (EPR) spectrometers for portable magnetic resonance (MR) applications. We focus the discussion on the application of integrated circuit technology for the miniaturization of the NMR and EPR spectrometer hardware and/or the detector and we will briefly touch on magnet technology. Finally, we will summarize current challenges of chip-integrated spectrometers and give an outlook on future applications of mobile MR spectrometers.

Efficacy of a Technology-Enhanced Community Health Nursing Intervention vs Standard of Care for Female Adolescents and Young Adults With Pelvic Inflammatory Disease: A Randomized Clinical Trial

IMPORTANCE

Pelvic inflammatory disease (PID) is a common reproductive health disorder that disproportionately affects female adolescents and young adults. Despite data indicating poor adherence and adverse outcomes among those who experience subsequent Neisseria gonorrhoeae and Chlamydia trachomatis infection, few trials have been designed to address this public health need.

OBJECTIVE

To examine the efficacy of a technology-enhanced community health nursing (TECH-N) intervention vs standard of care for improving PID self-management behaviors and 90-day longitudinal prevalence of N gonorrhoeae and C trachomatis infection.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial of the TECH-N intervention was conducted among female patients 13 to 25 years of age diagnosed with mild to moderate PID who were being discharged to outpatient treatment from September 6, 2012, to December 8, 2016, at a large academic medical center. The final analysis of data was completed in November 2018. This study compared the efficacy of the intervention with that of the standard of care using an intention-to-treat analysis.

INTERVENTIONS

Enrolled participants completed an audio computer-assisted self-interview, provided specimens for N gonorrhoeae and C trachomatis testing, and were randomized to standard treatment (n = 137) or the TECH-N intervention (n = 149). Intervention participants received text-messaging support and a community health nurse visit within 5 days of diagnosis. Change in the prevalence of N gonorrhoeae and C trachomatis infection was estimated with logistic regression. The N gonorrhoeae and C trachomatis positivity rate over time was evaluated using generalized estimating equations.

MAIN OUTCOMES AND MEASURES

The primary outcome was the prevalence of N gonorrhoeae and C trachomatis infection at 90-day follow-up. The secondary outcome was adherence to the Centers for Disease Control and Prevention recommendations for self-care.

RESULTS

A total of 286 patients (mean [SD] age, 18.8 [2.5] years; 268 [93.7%] African American) participated in the study. Although the study groups were demographically similar, the intervention group had a higher baseline rate of C trachomatis infection (45 of 139 [32.4%] vs 25 of 132 [18.9%], P = .01). Although N gonorrhoeae and C trachomatis positivity was not statistically different between groups at 90-day follow-up (6 of 135 [4.4%] vs 13 of 125 [10.4%], P = .07), the differential rate of decrease was significantly higher in the intervention group (48 of 140 [34.4%] to 6 of 135 [4.4%] compared with 34 of 133 [25.6%] to 13 of 112 [10.4%], P = .02). Intervention participants were more likely to receive the Centers for Disease Control and Prevention-recommended short-term follow-up visit compared with the control group (131 of 139 [94.2%] vs 20 of 123 [16.3%], P < .001).

CONCLUSIONS AND RELEVANCE

Adolescent and young adults with PID in the TECH-N intervention were more likely to experience decreases in N gonorrhoeae and C trachomatis positivity compared with the control group and to receive short-term clinical assessment. These findings suggest that the TECH-N intervention should be considered as a potential enhancement of standard of care approaches for management of female adolescents and young adults with mild to moderate PID in urban communities facing significant sexually transmitted infection disparities.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01640379.

Under Prescription of Epinephrine to Medicaid Patients in the Pediatric Emergency Department

Objective. To describe pediatric Medicaid patients with pediatric emergency department (PED) visits for anaphylaxis who received epinephrine auto-injector (EAI) prescriptions in the ED versus those who did not; and to compare patients who filled their prescriptions versus those who did not. Methods. We conducted a cross-sectional study of Medicaid patients aged 0 to 21 years presenting to 2 PEDs, with symptoms meeting the National Institute of Allergy and Infectious Diseases criteria for anaphylaxis, between July 2012 and July 2014. Results. We identified 86 patients across the 2 hospitals with a confirmed diagnosis of anaphylaxis in the PED. Of these, 55 (64%, 95% confidence interval [CI] = 53% to 74%) received a prescription for an EAI during their ED visit. Forty-two (68%; 95% CI = 56% to 80%) received a prescription for EAI in Hospital 1 versus 13 (54%; 95% CI = 33% to 74%) in Hospital 2. Medicaid prescription fill rates were available for Hospital 1. Of the 42 who received an EAI prescription, 36 (86%; 95% CI = 75% to 96%) filled these prescriptions with Medicaid. Of the 20 (32%) out of 62 patients with anaphylaxis who did not receive prescriptions for an EAI, only 5 had previously filled prescriptions for epinephrine. Conclusion. Previous Medicaid patient prescription adherence data suggested that these patients would have a low EAI prescription fill rate. We found Medicaid patients who received prescriptions for an EAI after the ED visit for anaphylaxis filled them; however, a considerable proportion of anaphylaxis visits had no EAI prescription provided at discharge.

Contributions to single-shot energy exchanges in open quantum systems

The exchange of energy between a classical open system and its environment can be analyzed for a single run of an experiment using the phase-space trajectory of the system. By contrast, in the quantum regime such energy exchange processes must be defined for an ensemble of runs of the same experiment based on the reduced system density matrix. Single-shot approaches based on stochastic wave functions have been proposed for quantum systems that are continuously monitored or weakly coupled to a heat bath. However, for systems strongly coupled to the environment and not continuously monitored, a single-shot analysis has not been attempted because no system wave function exists for such systems within the standard formulation of quantum theory. Using the notion of the conditional wave function of a quantum system, we derive here an exact formula for the rate of total energy change in an open quantum system, valid for arbitrary coupling between the system and the environment. In particular, this allows us to identify three distinct contributions to the total energy flow: an external contribution coming from the explicit time dependence of the Hamiltonian, an interaction contribution associated with the interaction part of the Hamiltonian, and an entanglement contribution, directly related to the presence of entanglement between the system and its environment. Given the close connection between weak values and the conditional wave function, the approach presented here provides a new avenue for experimental studies of energy fluctuations in open quantum systems.

Practice Variation in the Evaluation and Disposition of Febrile Infants ≤60 Days of Age

BACKGROUND

Febrile infants commonly present to emergency departments for evaluation.

OBJECTIVE

We describe the variation in diagnostic testing and hospitalization of febrile infants ≤60 days of age presenting to the emergency departments in the Pediatric Emergency Care Applied Research Network.

METHODS

We enrolled a convenience sample of non-critically ill-appearing febrile infants (temperatures ≥38.0°C/100.4°F) ≤60 days of age who were being evaluated with blood cultures in 26 Pediatric Emergency Care Applied Research Network emergency departments between 2008 and 2013. Patients were divided into younger (0-28 days of age) and older (29-60 days of age) cohorts for analysis. We evaluated diagnostic testing and hospitalization rates by infant age group using chi-square tests and by site using analysis of variance.

RESULTS

Four thousand seven hundred seventy-eight patients were eligible for analysis, of whom 1517 (32%) were 0-28 days of age. Rates of lumbar puncture and hospitalization were high (>90%) among infants ≤28 days of age, with chest radiography (35.5%) and viral testing (66.2%) less commonly obtained. Among infants 29-60 days of age, lumbar puncture (69.5%) and hospitalization (64.4%) rates were lower and declined with increasing age, with chest radiography (36.5%) use unchanged and viral testing (52.7%) slightly decreased. There was substantial variation between sites in the older cohort of infants, with lumbar puncture and hospitalization rates ranging from 40% to 90%.

CONCLUSIONS

The evaluation and disposition of febrile infants ≤60 days of age is highly variable, particularly among infants who are 29-60 days of age. This variation demonstrates an opportunity to modify diagnostic and management strategies based on current epidemiology to safely decrease invasive testing and hospitalization.

A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections

IMPORTANCE

In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs.

OBJECTIVE

To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs.

DESIGN, SETTING, AND PARTICIPANTS

Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018.

EXPOSURES

Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis.

MAIN OUTCOMES AND MEASURES

Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis.

RESULTS

We derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to convert to ×109 per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia.

CONCLUSIONS AND RELEVANCE

We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.

Risk of Bacterial Coinfections in Febrile Infants 60 Days Old and Younger with Documented Viral Infections

OBJECTIVE

To determine the risk of serious bacterial infections (SBIs) in young febrile infants with and without viral infections.

STUDY DESIGN

Planned secondary analyses of a prospective observational study of febrile infants 60 days of age or younger evaluated at 1 of 26 emergency departments who did not have clinical sepsis or an identifiable site of bacterial infection. We compared patient demographics, clinical, and laboratory findings, and prevalence of SBIs between virus-positive and virus-negative infants.

RESULTS

Of the 4778 enrolled infants, 2945 (61.6%) had viral testing performed, of whom 1200 (48.1%) were virus positive; 44 of the 1200 had SBIs (3.7%; 95% CI, 2.7%-4.9%). Of the 1745 virus-negative infants, 222 had SBIs (12.7%; 95% CI, 11.2%-14.4%). Rates of specific SBIs in the virus-positive group vs the virus-negative group were: UTIs (33 of 1200 [2.8%; 95% CI, 1.9%-3.8%] vs 186 of 1745 [10.7%; 95% CI, 9.2%-12.2%]) and bacteremia (9 of 1199 [0.8%; 95% CI, 0.3%-1.4%] vs 50 of 1743 [2.9%; 95% CI, 2.1%-3.8%]). The rate of bacterial meningitis tended to be lower in the virus-positive group (0.4%) than in the viral-negative group (0.8%); the difference was not statistically significant. Negative viral status (aOR, 3.2; 95% CI, 2.3-4.6), was significantly associated with SBI in multivariable analysis.

CONCLUSIONS

Febrile infants ≤60 days of age with viral infections are at significantly lower, but non-negligible risk for SBIs, including bacteremia and bacterial meningitis.

Energy-temperature uncertainty relation in quantum thermodynamics

It is known that temperature estimates of macroscopic systems in equilibrium are most precise when their energy fluctuations are large. However, for nanoscale systems deviations from standard thermodynamics arise due to their interactions with the environment. Here we include such interactions and, using quantum estimation theory, derive a generalised thermodynamic uncertainty relation valid for classical and quantum systems at all coupling strengths. We show that the non-commutativity between the system's state and its effective energy operator gives rise to quantum fluctuations that increase the temperature uncertainty. Surprisingly, these additional fluctuations are described by the average Wigner-Yanase-Dyson skew information. We demonstrate that the temperature's signal-to-noise ratio is constrained by the heat capacity plus a dissipative term arising from the non-negligible interactions. These findings shed light on the interplay between classical and non-classical fluctuations in quantum thermodynamics and will inform the design of optimal nanoscale thermometers.

A qualitative quantum rate model for hydrogen transfer in soybean lipoxygenase

The hydrogen transfer reaction catalysed by soybean lipoxygenase (SLO) has been the focus of intense study following observations of a high kinetic isotope effect (KIE). Today high KIEs are generally thought to indicate departure from classical rate theory and are seen as a strong signature of tunnelling of the transferring particle, hydrogen or one of its isotopes, through the reaction energy barrier. In this paper, we build a qualitative quantum rate model with few free parameters that describes the dynamics of the transferring particle when it is exposed to energetic potentials exerted by the donor and the acceptor. The enzyme's impact on the dynamics is modelled by an additional energetic term, an oscillatory contribution known as "gating." By varying two key parameters, the gating frequency and the mean donor-acceptor separation, the model is able to reproduce well the KIE data for SLO wild-type and a variety of SLO mutants over the experimentally accessible temperature range. While SLO-specific constants have been considered here, it is possible to adapt these for other enzymes.

Patient Satisfaction and Treatment Adherence for Urban Adolescents and Young Adults with Pelvic Inflammatory Disease

Objectives

Urban adolescents with pelvic inflammatory disease (PID) often seek care in emergency departments (ED). This study examines the effect of the ED patient experience - wait time (WT) and length of stay (LOS) - on satisfaction and medication adherence among urban adolescents with PID.

Methods

Adolescents with PID were enrolled in an urban teaching hospital ED. Chart data were matched with 2-week interview queries about satisfaction and medication adherence. Chi-square and logistic regression analyses evaluated the relationships between WT, LOS, provider type, satisfaction, and medication adherence.

Results

Of 83 participants, 96% report satisfaction with care, but only 45% report medication adherence. Mean WT was 55 minutes and mean LOS 200 minutes. Patients with higher LOS were less adherent with medication; this relationship became non-significant after adjustments. Patients seen by trainees had much longer LOS, but no differences in satisfaction or medication adherence.

Conclusions

Urban adolescents with PID report satisfaction with ED care despite prolonged LOS and medication adherence is poor. Optimization of ED workflows may improve outcomes in young women with PID.

Entropy production and time asymmetry in the presence of strong interactions

It is known that the equilibrium properties of open classical systems that are strongly coupled to a heat bath are described by a set of thermodynamic potentials related to the system's Hamiltonian of mean force. By adapting this framework to a more general class of nonequilibrium states, we show that the equilibrium properties of the bath can be well defined, even when the system is arbitrarily far from equilibrium and correlated with the bath. These states, which retain a notion of temperature, take the form of conditional equilibrium distributions. For out-of-equilibrium processes we show that the average entropy production quantifies the extent to which the system and bath state is driven away from the conditional equilibrium distribution. In addition, we show that the stochastic entropy production satisfies a generalized Crooks relation and can be used to quantify time asymmetry of correlated nonequilibrium processes. These results naturally extend the familiar properties of entropy production in weakly coupled systems to the strong coupling regime. Experimental measurements of the entropy production at strong coupling could be pursued using optomechanics or trapped-ion systems, which allow strong coupling to be engineered.

Association of RNA Biosignatures With Bacterial Infections in Febrile Infants Aged 60 Days or Younger

IMPORTANCE

Young febrile infants are at substantial risk of serious bacterial infections; however, the current culture-based diagnosis has limitations. Analysis of host expression patterns ("RNA biosignatures") in response to infections may provide an alternative diagnostic approach.

OBJECTIVE

To assess whether RNA biosignatures can distinguish febrile infants aged 60 days or younger with and without serious bacterial infections.

DESIGN, SETTING, AND PARTICIPANTS

Prospective observational study involving a convenience sample of febrile infants 60 days or younger evaluated for fever (temperature >38° C) in 22 emergency departments from December 2008 to December 2010 who underwent laboratory evaluations including blood cultures. A random sample of infants with and without bacterial infections was selected for RNA biosignature analysis. Afebrile healthy infants served as controls. Blood samples were collected for cultures and RNA biosignatures. Bioinformatics tools were applied to define RNA biosignatures to classify febrile infants by infection type.

EXPOSURE

RNA biosignatures compared with cultures for discriminating febrile infants with and without bacterial infections and infants with bacteremia from those without bacterial infections.

MAIN OUTCOMES AND MEASURES

Bacterial infection confirmed by culture. Performance of RNA biosignatures was compared with routine laboratory screening tests and Yale Observation Scale (YOS) scores.

RESULTS

Of 1883 febrile infants (median age, 37 days; 55.7% boys), RNA biosignatures were measured in 279 randomly selected infants (89 with bacterial infections-including 32 with bacteremia and 15 with urinary tract infections-and 190 without bacterial infections), and 19 afebrile healthy infants. Sixty-six classifier genes were identified that distinguished infants with and without bacterial infections in the test set with 87% (95% CI, 73%-95%) sensitivity and 89% (95% CI, 81%-93%) specificity. Ten classifier genes distinguished infants with bacteremia from those without bacterial infections in the test set with 94% (95% CI, 70%-100%) sensitivity and 95% (95% CI, 88%-98%) specificity. The incremental C statistic for the RNA biosignatures over the YOS score was 0.37 (95% CI, 0.30-0.43).

CONCLUSIONS AND RELEVANCE

In this preliminary study, RNA biosignatures were defined to distinguish febrile infants aged 60 days or younger with vs without bacterial infections. Further research with larger populations is needed to refine and validate the estimates of test accuracy and to assess the clinical utility of RNA biosignatures in practice.

Recruitment of Minority Adolescents and Young Adults into Randomised Clinical Trials: Testing the Design of the Technology Enhanced Community Health Nursing (TECH-N) Pelvic Inflammatory Disease Trial

PURPOSE

Pelvic inflammatory disease (PID) disproportionately affects adolescent and young adult (AYA) women and can negatively influence reproductive health trajectories. Few randomized controlled trials (RCTs) have focused on strategies to improve outpatient adherence or to reduce reproductive morbidity in this population. This paper describes the research methods and preliminary effectiveness of recruitment, retention, and intervention strategies employed in a novel RCT designed to test a technology-enhanced community-health nursing (TECH-N) intervention among urban AYA with PID.

METHODS

AYA women aged 13-25 years were recruited during acute PID visits in outpatient clinics and emergency departments (ED) to participate in this IRB-approved trial. Participants completed an audio-computerized self-interview (ACASI), provided vaginal specimens, and were randomized to standard treatment or the intervention. Intervention participants received text-messaging support for 30 days and a community health nurse (CHN) interventionist performed a home visit with clinical assessment within 5 days after enrollment. All patients received a full course of medications and completed research visits at 14-days (adherence), 30 days and 90 days with by an outreach worker. STI testing performed at the 30-and 90-day visits. Exploratory analyses using descriptive statistics were conducted to examine recruitment, retention, and follow-up data to test the overall design of the intervention.

RESULTS

In the first 48 months, 64% of 463 patients were eligible for the study and 81.2% of 293 eligible patients were recruited for the study (63.3%); 238 (81.2%) of eligible patients were enrolled. Most participants were African American (95.6%) with a mean age of 18.6 (2.3). Ninety-four percent of individuals assigned to the TECH-N intervention completed the nursing visits. All completed visits have been within the 5-day window and over 90% of patients in both arms have been retained over the 3-month follow-up period. Biological data suggests a shift in the biological milieu with the predominance of Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis infections.

CONCLUSIONS

Preliminary data from the TECH-N study demonstrated that urban, low-income, minority AYA with PID can effectively be recruited and retained to participate in sexual and reproductive health RCTs with sufficient investment in the design and infrastructure of the study. Community-based sexual health interventions appear to be both feasible and acceptable in this population.

Long-term prediction of changes in health status, frailty, nursing care and mortality in community-dwelling senior citizens—results from the Longitudinal Urban Cohort Ageing Study (LUCAS)

Background

The detection of incipient functional decline in elderly persons is not an easy task. Here, we propose the self-reporting Functional Ability Index (FA index) suitable to screen functional competence in senior citizens in the community setting. Its prognostic validity was investigated in the Longitudinal Urban Cohort Ageing Study (LUCAS).

Methods

This index is based equally on both, resources and risks/functional restrictions which precede ADL limitations. Since 2001, the FA index was tested in the LUCAS cohort without any ADL restrictions at baseline (n = 1,679), and followed up by repeated questionnaires in Hamburg, Germany.

Results

Applying the index, 1,022 LUCAS participants were initially classified as Robust (60.9%), 220 as postRobust (13.1%), 172 as preFrail (10.2%) and 265 as Frail (15.8%). This classification correlated with self-reported health, chronic pain and depressive mood (rank correlations 0.42, 0.26, 0.21; all p < .0001). Survival analyses showed significant differences between these classes as determined by the FA index: the initially Robust survived longest, the Frail shortest (p < .0001). Analyses of the time to need of nursing care revealed similar results. Significant differences persisted after adjustment for age, sex and self-reported health.

Conclusions

Disability free lifetime and its development over time are important topics in public health. In this context, the FA index presented here provides answers to two questions. First, how to screen the heterogeneous population of community-dwelling senior citizens, i.e. for their functional ability/competence, and second, how far away they are from disability/dependency. Furthermore, the index provides a tool to address the urgent question whether incipient functional decline/incipient frailty can be recognized early to be influenced positively.

The FA index predicted change in functional status, future need of nursing care, and mortality in an unselected population of community-dwelling seniors. It implies an operational specification of the classification into Robust, postRobust, preFrail and Frail. Based on a self-administered questionnaire, the FA index allows easy screening of elderly persons for declining functional competence. Thereby, incipient functional decline is recognized, e.g. in GPs’ practices and senior community health centers, to initiate early appropriate preventive action.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2318-14-141) contains supplementary material, which is available to authorized users.

Nanoscale temperature measurements using non-equilibrium Brownian dynamics of a levitated nanosphere

Einstein realized that the fluctuations of a Brownian particle can be used to ascertain the properties of its environment. A large number of experiments have since exploited the Brownian motion of colloidal particles for studies of dissipative processes, providing insight into soft matter physics and leading to applications from energy harvesting to medical imaging. Here, we use heated optically levitated nanospheres to investigate the non-equilibrium properties of the gas surrounding them. Analysing the sphere's Brownian motion allows us to determine the temperature of the centre-of-mass motion of the sphere, its surface temperature and the heated gas temperature in two spatial dimensions. We observe asymmetric heating of the sphere and gas, with temperatures reaching the melting point of the material. This method offers opportunities for accurate temperature measurements with spatial resolution on the nanoscale, and provides a means for testing non-equilibrium thermodynamics.

Room temperature strong coupling between a microwave oscillator and an ensemble of electron spins

We demonstrate theoretically and experimentally the possibility to achieve the strong coupling regime at room temperature with a microwave electronic oscillator coupled with an ensemble of electron spins. The coupled system shows bistable behaviour, with a broad hysteresis and sharp transitions. The coupling strength and the hysteresis width can be adjusted through the number of spins in the ensemble, the temperature, and the microwave field strength.

[Resources and risks in old age: the LUCAS-I marker set for a classification of elderly people as fit, pre-frail and frail. First results on validity from the Longitudinal Urban Cohort Ageing Study (LUCAS), Hamburg]

BACKGROUND

There is a need for a simple self-administered instrument to assess frailty in community-dwelling seniors.

METHODS

We present a new marker set to assess the functional state of seniors. Contrary to current literature, we focus not only on risks, but also include resources. The questions relate to facts (ways to do things), rather than on subjective information (e.g. exhaustion). It was developed in the context of the Longitudinal Urban Cohort Ageing Study (LUCAS) in Hamburg, Germany.

RESULTS

The classification based on these questions proposes operational definitions of the terms fit, pre-frail and frail and is predictive for need for nursing care as well as mortality. A wealth of results establishes the validity of the categorisation compared to other health questions. One of the classification questions concerns cycling. For areas where cycling is not suitable, we propose to replace this question with one about independently walking 500 m. However, the cycling question appears to indicate frailty earlier.

CONCLUSION

The self-administered questionnaire provides a simple, cost-effective way to screen seniors for early signs of declining function in order to start preventive action.

The Longitudinal Urban Cohort Ageing Study (LUCAS): study protocol and participation in the first decade

Background

We present concept, study protocol and selected baseline data of the Longitudinal Urban Cohort Ageing Study (LUCAS) in Germany. LUCAS is a long-running cohort study of community-dwelling seniors complemented by specific studies of geriatric patients or diseases. Aims were to (1) Describe individual ageing trajectories in a metropolitan setting, documenting changes in functional status, the onset of frailty, disability and need of care; (2) Find determinants of healthy ageing; (3) Assess long-term effects of specific health promotion interventions; (4) Produce results for health care planning for fit, pre-frail, frail and disabled elderly persons; (5) Set up a framework for embedded studies to investigate various hypotheses in specific subgroups of elderly.

Methods/Design

In 2000, twenty-one general practitioners (GPs) were recruited in the Hamburg metropolitan area; they generated lists of all their patients 60 years and older. Persons not terminally ill, without daily need of assistance or professional care were eligible. Of these, n = 3,326 (48 %) agreed to participate and completed a small (baseline) and an extensive health questionnaire (wave 1). In 2007/2008, a re-recruitment took place including 2,012 participants: 743 men, 1,269 women (647 deaths, 197 losses, 470 declined further participation). In 2009/2010 n = 1,627 returned the questionnaire (90 deaths, 47 losses, 248 declined further participation) resulting in a good participation rate over ten years with limited and quantified dropouts. Presently, follow-up data from 2007/2008 (wave 2) and 2009/2010 (wave 3) are available. Data wave 4 is due in 2011/2012, and the project will be continued until 2013. Information on survival and need of nursing care was collected continuously and cross-checked against official records. We used Fisher’s exact test and t-tests. The study served repeatedly to evaluate health promotion interventions and concepts.

Discussion

LUCAS shows that a cohort study of older persons is feasible and can maintain a good participation rate over ten years, even when extensive self-reported health data are collected repeatedly through self-filled questionnaires. Evidently individual health developments of elderly persons can be tracked quantifying simultaneously behaviour, co-morbidity, functional competence and their changes. In future, we expect to generate results of significance about the five study aims listed above.

A qualitative assessment of factors that influence emergency medical services partnerships in prehospital research

OBJECTIVES

  Recent efforts to increase emergency medical services (EMS) prehospital research productivity by focusing on reducing systems-related barriers to research participation have had limited effect. The objective of this study was to explore the barriers and motivators to participating in research at the agency and provider levels and to solicit suggestions for improving the success of prehospital research projects.

METHODS

  The authors conducted a qualitative exploratory study of EMS personnel using focus group and focused interview methodology. EMS personnel affiliated with the Pediatric Emergency Care Applied Research Network (PECARN) hospitals were selected for participation using a purposive sampling plan. Exploratory questioning identified identified factors that influence participation in research and suggestions for ensuring successful research partnerships. Through iterative coding and analysis, the factors and suggestions that emerged from the data were organized into a behavioral change planning model.

RESULTS

  Fourteen focus groups were conducted, involving 88 EMS prehospital providers from 11 agencies. Thirty-five in-depth interviews with EMS administrators and researchers were also conducted. This sample was representative of prehospital personnel servicing the PECARN catchment area and was sufficient for analytical saturation. From the transcripts, the authors identified 17 barriers and 12 motivators to EMS personnel participation in research. Central to these data were patient safety, clarity of research purpose, benefits, liability, professionalism, research training, communication with the research team, reputation, administrators' support, and organizational culture. Interviewees also made 29 suggestions for increasing EMS personnel participation in research. During data analysis, the PRECEDE/PROCEED planning model was chosen for behavioral change to organize the data. Important to this model, factors and suggestions were mapped into those that predispose (knowledge, attitudes, and beliefs), reinforce (social support and norms), and/or enable (organizational) the participation in prehospital research.

CONCLUSIONS

  This study identified factors that influence the participation of EMS personnel in research and gathered suggestions for improvement. These findings were organized into the PRECEDE/PROCEED planning model that may help researchers successfully plan, implement, and complete prehospital research projects. The authors provide guidance to improve the research process including directly involving EMS providers throughout, a strong theme that emerged from the data. Future work is needed to determine the validity of this model and to assess if these findings are generalizable across prehospital settings other than those affiliated with PECARN.

[Rehabilitation instead of nursing care. Current state and future demand of geriatric rehabilitation]

In Germany, the term "rehabilitation instead of nursing care" represents an established legal claim and is also an imperative part within the general concept of comprehensive healthcare provision, reflecting the ongoing demographic and epidemiological developments. This report gives an overview on the rationale, the principles, and organizational conception of geriatric rehabilitation. This is completed by an assessment of existing structures for service provision and future demands of specific geriatric rehabilitation and geriatric care. There are well-established possibilities and facilities to realize the legal claim "rehabilitation instead of nursing care." However, these possibilities have to be further optimized in order to detect need earlier and to make adequate use of the potential resources in the growing number of old-aged persons.

Foot care education in patients with diabetes at low risk of complications: a consensus statement

AIMS

To define and agree a practical educational framework for delivery by all healthcare professionals managing patients with diabetes, particularly those at low risk of developing foot complications.

METHODS

A consensus meeting of a multidisciplinary expert panel. Prior to the meeting, relevant clinical papers were disseminated to the panel for review. The consensus was largely based upon the experts' clinical experience and judgement.

RESULTS

Four main health behaviours were identified for those at low risk of developing foot complications, namely: control of blood glucose levels; attendance at annual foot screening examination; reporting of any changes in foot health immediately; and the engagement in a simple daily foot care routine.

CONCLUSION

There is currently little evidence-based literature to support specific foot care practices. Patients with diabetes at low risk of developing complications should be encouraged to undertake a basic foot care regimen to reduce their likelihood of developing complications.

Pneumatic compression with foot pumps facilitates early postoperative mobilisation in total knee arthroplasty

Deep-vein thrombosis (DVT) and pulmonary embolism (PE) represent life-threatening postoperative complications frequently responsible for in-hospital mortality following total knee arthroplasty (TKA). Mechanical prophylaxis in the form of a foot pump offers an alternative to pharmacological and physical therapy. The aim of this prospective and randomised study was to examine the clinical efficacy of the A-V Impulse (AVI) system in reduction of soft-tissue swelling of the lower limb following a TKA. A total of 80 patients undergoing cemented TKA between September 2005 and December 2006 were randomised into two groups of 40 patients (n¹ = 40, n² = 40) during the 16-month study period. All patients received a subcutaneous dose of low molecular weight heparin (LMWH) (Enoxaparin/Clexane® 40 mg) once daily beginning 24 hours prior to the operation. The mean age for the groups n¹ and n² were 68.93 and 68.15 years, respectively. The reduction of soft-tissue swelling in the n¹ group was significantly higher (p < 0.05) compared with n². Evaluation of body mass index (BMI) with regard to the average reduction of soft-tissue swelling showed no significant influence (p < 0.05). The better function of the operated knee in group AVI was a significant predictor for improved agility and mobility (p < 0.01). No complications were reported for the application of the AVI. No ultrasonographic evidence of DVT or PE was found in any of the 80 patients during the investigative time period of eight days. After three months, there was no evidence of a symptomatic DVT.