Telementoring: a novel approach to reducing the osteoporosis treatment gap

Bone Health ECHO telementors healthcare professionals to develop the clinical skills needed to provide advanced levels of care for patients with skeletal disorders. The goal of this mentorship model is to improve osteoporosis care in underserved areas, decrease the need for referral to specialty centers, and reduce the osteoporosis treatment gap.

INTRODUCTION

The Project ECHO (Extension for Community Healthcare Outcomes) model of telementoring has been shown to improve the care individuals with chronic hepatitis C. ECHO has since been adapted to the address unmet needs in the care of other chronic complex diseases and recently applied to the care of osteoporosis and metabolic bone diseases.

METHODS

Bone Health ECHO outcomes are assessed through an electronic data collector asking qualitative questions about self-efficacy. This is a progress report of Bone Health ECHO from its launch in October 2015 through May 2016.

RESULTS

A total of 31 weekly Bone Health ECHO clinics were held over 8 months, with 43 individuals participating at least one clinic session. The number of clinics attended range from 1 to 30, with 13 learners attending more than 10 clinics and an average of 11 learners per clinic. Self-efficacy information provided by learners was diverse with many favorable anticipated changes in clinical practice.

CONCLUSIONS

Bone Health ECHO telementors healthcare professionals in underserved areas to provide advanced levels of care for patients with skeletal disorders. The experience of Bone Health ECHO will guide the development of similar telementoring clinics in other locations. More data are needed to fully evaluate this novel approach to reducing the osteoporosis treatment gap.

Macronutrient processing by temperate lakes: A dynamic model for long-term, large-scale application

We developed a model of the biogeochemical and sedimentation behaviour of carbon (C), nitrogen (N) and phosphorus (P) in lakes, designed to be used in long-term (decades to centuries) and large-scale (10⁴-10⁵km²) macronutrient modelling, with a focus on human-induced changes. The model represents settling of inflow suspended particulate matter, production and settling of phytoplankton, decomposition of organic matter in surface sediment, denitrification, and DOM flocculation and decomposition. The model uses 19 parameters, 13 of which are fixed a priori. The remaining 6 were obtained by fitting data from 109 temperate lakes, together with other information from the literature, which between them characterised the stoichiometric incorporation of N and P into phytoplankton via photosynthesis, whole-lake retention of N and P, N removal by denitrification, and the sediment burial of C, N and P. To run the model over the long periods of time necessary to simulate sediment accumulation and properties, simple assumptions were made about increases in inflow concentrations and loads of dissolved N and P and of catchment-derived particulate matter (CPM) during the 20th century. Agreement between observations and calculations is only approximate, but the model is able to capture wide trends in the lakewater and sediment variables, while also making reasonable predictions of net primary production. Modelled results suggest that allochthonous sources of carbon (CPM and dissolved organic matter) contribute more to sediment carbon than the production and settling of algal biomass, but the relative contribution due to algal biomass has increased over time. Simulations for 8 UK lakes with sediment records suggest that during the 20th century average carbon fixation increased 6-fold and carbon burial in sediments by 70%, while the delivery of suspended sediment from the catchments increased by 40% and sediment burial rates of N and P by 131% and 185% respectively.

Long-term macronutrient stoichiometry of UK ombrotrophic peatlands

In this paper we report new data on peat carbon (C), nitrogen (N) and phosphorus (P) concentrations and accumulation rates for 15 sites in the UK. Concentrations of C, N and P measured in peat from five ombrotrophic blanket mires, spanning 4000-10,000years to present were combined with existing nutrient data from ten Scottish ombrotrophic peat bogs to provide the first UK perspective on millennial scale macronutrient concentrations in ombrotrophic peats. Long-term average C, N and P concentrations (0-1.25m) for the UK are 54.8, 1.56 and 0.039wt%, of similar magnitude to the few published comparable sites worldwide. The uppermost peat (0-0.2m) is enriched in P and N (51.0, 1.86, and 0.070wt%) relative to the deeper peat (0.5-1.25m, 56.3, 1.39, and 0.027wt%). Long-term average (whole core) accumulation rates of C, N and P are 25.3±2.2gCm^-2year^-1 (mean±SE), 0.70±0.09gNm^-2year^-1 and 0.018±0.004gPm^-2year^-1, again similar to values reported elsewhere in the world. The two most significant findings are: 1) that a regression model of N concentration on P concentration and mean annual precipitation, based on global meta data for surface peat samples, can explain 54% of variance in N concentration in these UK peat profiles; and 2) budget calculations for the UK peat cores yield an estimate for long-term average N-fixation of 0.8gm^-2year^-1. Our UK results, and comparison with others sites, corroborate published estimates of N storage in northern boreal peatlands through the Holocene as ranging between 8 and 15Pg N. However, the observed correlation of N% with both mean annual precipitation and P concentration allows a potential bias in global estimates that do not take this into account. The peat sampling data set has been deposited at the NERC Data Centre (Toberman et al., 2016).

Atmospheric deposition of phosphorus to land and freshwater

We compiled published and newly-obtained data on the directly-measured atmospheric deposition of total phosphorus (TP), filtered total phosphorus (FTP), and inorganic phosphorus (PO4-P) to open land, lakes, and marine coasts. The resulting global data base includes data for c. 250 sites, covering the period 1954 to 2012. Most (82%) of the measurement locations are in Europe and North America, with 44 in Africa, Asia, Oceania, and South-Central America. The deposition rates are log-normally distributed, and for the whole data set the geometric mean deposition rates are 0.027, 0.019 and 0.14 g m(-2) a(-1) for TP, FTP and PO4-P respectively. At smaller scales there is little systematic spatial variation, except for high deposition rates at some sites in Germany, likely due to local agricultural sources. In cases for which PO4-P was determined as well as one of the other forms of P, strong parallels between logarithmic values were found. Based on the directly-measured deposition rates to land, and published estimates of P deposition to the oceans, we estimate a total annual transfer of P to and from the atmosphere of 3.7 Tg. However, much of the phosphorus in larger particles (principally primary biological aerosol particles) is probably redeposited near to its origin, so that long-range transport, important for tropical forests, large areas of peatland and the oceans, mainly involves fine dust from deserts and soils, as described by the simulations of Mahowald et al. (Global Biogeochemical Cycles 22, GB4026, 2008). We suggest that local release to the atmosphere and subsequent deposition bring about a pseudo-diffusive redistribution of P in the landscape, with P-poor ecosystems, for example ombrotrophic peatlands and oligotrophic lakes, gaining at the expense of P-rich ones. Simple calculations suggest that atmospheric transport could bring about significant local redistribution of P among terrestrial ecosystems. Although most atmospherically transported P is natural in origin, local transfers from fertilised farmland to P-poor ecosystems may be significant, and this requires further research.

Increased accumulation of sulfur in lake sediments of the high arctic

We report a synchronous increase in accumulation of reduced inorganic sulfur since c. 1980 in sediment cores from eight of nine lakes studied in the Canadian Arctic and Svalbard (Norway). Sediment incubations and detailed analyses of sediment profiles from two of the lakes indicate that increases in sulfur accumulation may be due ultimately to a changing climate. Warming-induced lengthening of the ice-free season is resulting in well-documented increases in algal production and sedimentation of the resulting detrital matter. Algal detritus is a rich source of labile carbon, which in these sediments stimulates dissimilatory sulfate reduction. The sulfide produced is stored in sediment (as acid volatile sulfide), converted to other forms of sulfur, or reoxidized to sulfate and lost to the water column. An acceleration of the sulfur cycle in Arctic lakes could have profound effects on important biogeochemical processes, such as carbon burial and mercury methylation.

Detecting atmospheric pollution in surface soils using magnetic measurements: a reappraisal using an England and Wales database

Industrial activity such as burning of fossil fuels produces magnetically enhanced particulates. These particulates consist of coarse-grained multidomain and stable single domain magnetic minerals. Two threshold values of low field magnetic susceptibility (chi(LF)) and frequency dependent susceptibility percentage (chi(FD)%) discriminate ferrimagnetic minerals of these sizes and can act as a tracer of magnetic pollution. Application of the thresholds to a magnetic topsoil data set (n=5656 across England and Wales) revealed 637 samples potentially dominated by pollution particulates. The magnetic parameters of these samples display a negative correlation with distance to urban areas and positive correlations with metals associated with anthropogenic activity (Cu, Pb, and Zn). Results of experimentation with threshold values and modelling of magnetic anomalies suggest that regional factors such as geology and potential for pedogenic secondary magnetic enhancement should be considered when setting threshold values.

Detecting atmospheric pollution in surface soils using magnetic measurements: a reappraisal using an England and Wales database

Industrial activity such as burning of fossil fuels produces magnetically enhanced particulates. These particulates consist of coarse-grained multidomain and stable single domain magnetic minerals. Two threshold values of low field magnetic susceptibility (chi(LF)) and frequency dependent susceptibility percentage (chi(FD)%) discriminate ferrimagnetic minerals of these sizes and can act as a tracer of magnetic pollution. Application of the thresholds to a magnetic topsoil data set (n=5656 across England and Wales) revealed 637 samples potentially dominated by pollution particulates. The magnetic parameters of these samples display a negative correlation with distance to urban areas and positive correlations with metals associated with anthropogenic activity (Cu, Pb, and Zn). Results of experimentation with threshold values and modelling of magnetic anomalies suggest that regional factors such as geology and potential for pedogenic secondary magnetic enhancement should be considered when setting threshold values.

TBT causes regime shift in shallow lakes

Tributyltin (TBT) is an organotin compound used since the early 1960s as a biocide in boat antifouling paints. Its use has been linked to a host of negative effects in marine ecosystems including malformations and imposex in Mollusca and acute toxicity in many other aquatic animals. Yet, the consequences of TBT use in freshwaters are largely unknown. Here, for the first time we reveal that TBT may have caused hitherto unsuspected damage to freshwater ecosystems. Through an analysis of dated sediment cores collected from a system of recreationally boated, shallow lakes, we show that first evidence of TBT is associated with a dramatic loss of submerged vegetation and associated diverse animal communities. Cause and effect are difficult to unravel in our study. However, we hypothesize that TBT, through reducing populations of grazing organisms in lakes already affected by eutrophication, promoted the replacement of macrophytes by phytoplankton, ultimately leading to a regime shift in the ecosystem. Our findings may have parallels in freshwater ecosystems all over the world.

Mercury and lead budgets for Lochnagar, a Scottish mountain lake and its catchment

Lochnagar is a mountain lake located to the southeast of the Cairngorm Mountains in Scotland. The inputs and outputs of Hg and Pb and their distribution within the various ecosystem compartments were measured. Further, 17 sediment cores and 10 catchment peat cores were taken and dated using spheroidal carbonaceous particle (SCP) and 210Pb techniques. Total and anthropogenic Hg and Pb inventories since the 1860s for the lake basin and the catchment peats were calculated using this multiple core strategy. Hg sediment flux profiles based on the whole lake basin show that the flux to the sediments increased from the 1880s until the 1970s. This was followed by a relatively stable period (1970s to the present), during which the flux was approximately twice that of the 1880s. Similarly, the Pb flux increased from the 1860s until the 1940s and was also followed by a relatively stable period through to the present. Hg and Pb budgets for the whole catchment for 1998 indicated that 78% of the Hg and 91% of the Pb input to the lake were transported from the catchment. Hence, the expected decline resulting from the decrease in the atmospheric deposition of Pb was obscured in the sediment record. It is estimated that 77% of the total Hg and 90% of the total Pb deposited since the 1860s, and stored in the upper layers of the catchment peat soils, are from anthropogenic sources. The increased storage of Hg and Pb in the catchment implies that this will be a major source of these metals for the lake for many years. This will delay the restoration of the lake system, despite reductions in emissions to the atmosphere and subsequent deposition.

Storage and distribution of trace metals and spheroidal carbonaceous particles (SCPs) from atmospheric deposition in the catchment peats of Lochnagar, Scotland

Lochnagar is a remote mountain lake to the south-east of the Cairngorm region in Scotland. Its catchment receives anthropogenic trace metals solely from atmospheric deposition. Ten peat cores were taken from the catchment and analysis confirmed that they have been contaminated by trace metals. The peats have an high affinity for trace metals and this results in metal accumulation in the surface peat layers. The formation of trace metal sulphides may also reduce remobilisation. In this way, trace metals derived from atmospheric deposition have been scavenged and accumulated. In contaminated peat layers, 77.4% Hg, 89.6% Pb, 93.4% Cu, 72.4% Zn and 86.5% Cd of the total stored are from anthropogenic sources. The accumulated trace metals in the peats can potentially influence the lake system through erosion. Spheroidal carbonaceous particle (SCP) profiles were used to date the peat cores. By referring to the SCP profiles in the peats and comparing these with the trace metal profiles in the lake sediments, the mobility of trace metals in the catchment peats is confirmed.

Efficacy of control measures in preventing nosocomial transmission of multidrug-resistant tuberculosis to patients and health care workers

OBJECTIVE

To assess the efficacy of control measures in decreasing nosocomial transmission of multidrug-resistant tuberculosis.

DESIGN

Retrospective cohort study.

SETTING

A teaching hospital in New York City.

POPULATION

40 patients hospitalized with multidrug-resistant tuberculosis (case-patients) and health care workers receiving tuberculin skin testing.

INTERVENTIONS

Centers for Disease Control and Prevention (CDC) 1990 guidelines for preventing transmission of tuberculosis, including 1) prompt isolation and treatment of patients with tuberculosis; 2) rapid diagnostic techniques for processing Mycobacterium tuberculosis specimens; 3) negative-pressure isolation rooms; and 4) molded surgical masks for health care workers.

MEASUREMENTS

Proportion of case-patients with nosocomially acquired tuberculosis and rate of tuberculin skin test conversion among health care workers before and after implementation of control measures.

RESULTS

The proportion of patients with multidrug-resistant strains of M. tuberculosis decreased after the interventions (10 of 70 [14%] compared with 30 of 95 [32%] patients before the intervention; relative risk [RR], 0.5; 95% CI, 0.2 to 0.9). Before onset of multidrug-resistant tuberculosis, case-patients in the intervention period were as likely to be hospitalized on high-risk wards containing patients with tuberculosis (4 of 10 compared with 17 of 30 patients; RR, 0.7; P = 0.5) but were less likely to be exposed to another case-patient with tuberculosis (1 of 10 compared with 20 of 30 patients; RR, 0.2; P = 0.003). Tuberculin skin test conversion rates for health care workers assigned to wards housing patients with tuberculosis were lower in the intervention period than in the preintervention period (4 of 78 [5%] compared with 15 of 90 [17%] conversions; P = 0.02), decreasing to levels observed for workers assigned to other wards (4 of 78 [5%] compared with 9 of 228 [4%] conversions; P = 0.7).

CONCLUSIONS

Implementing control measures reduced nosocomial transmission of multidrug-resistant strains to patients and health care workers.

Hafnia alvei. Respiratory tract isolates in a community hospital over a three-year period and a literature review

In a retrospective review, a group of seven patients were found to have a sputum culture positive for Hafnia alvei. Hafnia alvei is a Gram-negative enteric and oropharyngeal bacillus and usually is nonpathogenic. All our patients had a chronic underlying illness and one of the patients was endotracheally intubated at the time of the isolation of this organism. Six of seven patients had other organisms isolated along with H alvei, and only one patient had a pure growth of H alvei confirmed by a culture obtained from a bronchoscopic protected brush specimen. All isolates displayed resistance to conventional antibiotics including cephalosporins and penicillins. Although rare, H alvei may be a potential pathogen in a patient with a chronic underlying illness.

Epidemiologic analysis and genotypic characterization of a nosocomial outbreak of vancomycin-resistant enterococci

We are reporting on a nosocomial outbreak of 213 cases of vancomycin-resistant enterococcus infection involving 2,812 enterococcal isolates from patients over a period of 36 months. In 1990, the Enterococcus faecium vancomycin susceptibility rate was found to be 85.7% (36 of 42 cases), and an incidence of 10.9% (42 of 383) was noted. The 1991 data showed E. faecium with a vancomycin susceptibility rate of 61.8% (110 of 178) and an incidence of 26.0% (178 of 684). Subsequently, in 1992, the incidence of E. faecium increased to 34.0% (599 of 1,745), with a decreased vancomycin susceptibility rate of 25.8% (155 of 599). The E. faecalis vancomycin susceptibility rate remained near 97% (1,768 of 1,823) over the 36-month period. Of 115 vancomycin-resistant enterococcus (VRE) clinical isolates identified by the MicroScan MIC Combo-6 panels (Baxter Healthcare, Sacramento, Calif.), the agar dilution method indicated the resistance rate to be 92.3% (106 of 115) (high level), 3.5% (4 of 115) midlevel, and 3.5% (4 of 115) (low level). Genotypic characterization of 32 different VRE isolates by field-inversion gel electrophoresis demonstrated 19 dissimilar restriction endonuclease patterns, with 9 patterns associated with VRE quinolone resistance. Statistical analysis of case-control data for 32 patients with VRE infections indicated a positive association with intrabdominal surgical procedures (odds ratio, 24.12), multidrug therapy (odds ratio, 37.80), preexposure to vancomycin (odds ratio, 20.21), and death (odds ratio, 17.50).

Has reform taken us where we wanted to go?

ASIM's executive vice president assesses the history of physician payment reform and the implications for internists. Although the new fee schedule may not be perfect, the RBRVS is right on target--it reduces the disparities between payments for cognitive and procedural services.

RBRVS: still good news for physicians

Lately, many physicians have been saying they've become disillusioned with the RBRVS. They don't believe the physician payment reform will bring gains for their undervalued evaluation and management services. They don't trust the federal government to live up to its end of the bargain. However, no one should write off the RBRVS. As can be seen from the text below, RBRVS will protect undervalued evaluation and management services in an era of medicare budget-cutting; it will introduce fairness and rationality into the Medicare payment system; it will provide a basis for arguing against unfair cuts in reimbursement (such as the recent ban on payment for most EKG interpretations) and it will bring the profession together to fight against any further cuts in the Medicare program.

Helicobacter pylori infection in patients with acquired immune deficiency syndrome

A controlled study was conducted on patients with human immunodeficiency virus (HIV) infection referred for upper endoscopy to evaluate the prevalence of Helicobacter pylori (H. pylori) infection. Four different stains and culture for H. pylori were performed on biopsy specimens from the gastric antrum. Sixteen (40%) of 40 patients with acquired immune deficiency syndrome (AIDS) or AIDS-related complex (ARC) were diagnosed to be infected with H. pylori versus 14 (39%) of 36 age-matched control patients. Eight of 15 AIDS/ARC patients without AIDS-related esophagogastroduodenal findings (53%) were infected with H. pylori versus 8/25 (32%) with endoscopic findings typical of AIDS. No invasion of the lamina propria by H. pylori was noted in any patient. Active chronic gastritis was present in 60% of AIDS/ARC patients and 61% of controls. Fifty-eight and 59%, respectively, of active chronic gastritis cases were infected with H. pylori. All the H. pylori infections, except one, were found in patients with chronic gastritis. In AIDS/ARC patients, H. pylori infection and active chronic gastritis are as common as in other patients referred for upper endoscopy. They may play a pathogenic role, especially when endoscopic AIDS-related findings are lacking. Cell-mediated immune deficiency does not appear to increase the risk of infection with H. pylori.

Ciprofloxacin-resistant methicillin-resistant Staphylococcus aureus in an acute-care hospital

Use of ciprofloxacin as an alternative to vancomycin for treatment of methicillin-resistant Staphylococcus aureus infection has been paralleled by the emergence of resistant strains. This phenomenon has also been noticed in our hospital. To confirm our observation, methicillin and ciprofloxacin susceptibilities were tested by disk diffusion and broth microdilution techniques. We studied 83 methicillin-resistant Staphylococcus aureus isolates obtained from various sources over a 4-month period. Ciprofloxacin resistance (MIC, greater than 2 micrograms/ml) was detected in 69 isolates (83%). Prior use of ciprofloxacin was reported for 24 of 69 patients with ciprofloxacin-resistant strains and 0 of 14 patients with ciprofloxacin-susceptible strains. The day of detection during the hospital stay and the location of the source patient were not significantly different between resistant and susceptible strains. Bacteriophage typing showed a higher occurrence of nontypeable strains among ciprofloxacin-resistant strains (54%). Review of our microbiology register showed a progressive increase in the rate of resistance to ciprofloxacin during the first year of use, with initial rates being about 10% and recent rates being higher than 80%. On the other hand, methicillin-susceptible S. aureus remained uniformly susceptible to ciprofloxacin (98.4%). We conclude that prior use of ciprofloxacin is an important factor for the selection of ciprofloxacin-resistant strains and that ciprofloxacin has limited usefulness against methicillin-resistant S. aureus.

Membrane localization of the pertussis toxin-sensitive G-protein subunits alpha i-2 and alpha i-3 and expression of a metallothionein-alpha i-2 fusion gene in LLC-PK1 cells

The renal epithelial cell line LLC-PK1 has topographically distinct regulatory roles for the alpha subunits of pertussis toxin-sensitive guanine nucleotide regulatory proteins (alpha i subunit); these include the inhibition of adenylyl cyclase at the basolateral membrane and the stimulation of Na+ channel activity at the apical membrane. We now report that LLC-PK1 cells contain two members of the alpha i protein family, alpha i-2 and alpha i-3, which have distinct cellular locations consistent with their diverse functional roles. By using specific alpha i antibodies and immunofluorescence, the alpha i-2 subunit was found to be localized to the basolateral membrane, whereas the alpha i-3 subunit was concentrated in the Golgi and was also detectable at low levels on apical membranes in some cells. Induction of a chimeric mouse metallothionein 1-rat or canine alpha i-2 gene stably transfected into the LLC-PK1 cells produced an increase in the content of the alpha i-2 subunit, which was targeted only to the basolateral membrane. These findings suggest that alpha i subunit specificity for effectors may be achieved in polarized renal epithelial cells by their geographic segregation to different cellular membranes. The LLC-PK1 cell stably transfected with the metallothionein-alpha i-2 fusion gene will provide a model for the study of guanine nucleotide regulatory protein function in epithelia.