Workplace cardiovascular risk reduction by healthcare professionals-a systematic review

BACKGROUND

Cardiovascular disease has a significant impact on public health and is largely preventable by addressing modifiable risk factors. As most adults spend on average half of their waking hours at work, this provides a significant opportunity to address modifiable risk factors through health promotion interventions. Healthcare professionals have the knowledge and skills to provide workplace interventions aimed at cardiovascular risk reduction.

AIMS

This study was aimed to assess the literature regarding the effect of workplace interventions led by healthcare professionals on cardiovascular risk factors.

METHODS

Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, MEDLINE, PsycINFO and SPORTDiscus were systematically searched from inception to March 2021. Included studies evaluated impact of workplace interventions by healthcare professionals on cardiovascular health. Data on study design, baseline characteristics, interventions, outcomes and conclusions were extracted and qualitatively analysed.

RESULTS

Forty-five studies representing 77 633 participants were included in the analysis. Healthcare professionals involved included: nurses, nurse practitioners, physicians, dietitians, pharmacists, physician assistants, medical technicians/emergency medical technicians and physiotherapists. Workplace interventions by healthcare professionals generally improved surrogate markers of cardiovascular health. Success varied based on provider and nature of the intervention. Addressing motivation and including follow-up were key factors for successful intervention to reduce cardiovascular risk factors.

CONCLUSIONS

Workplace health promotion initiatives delivered by healthcare professionals may improve cardiovascular risk markers if they are evidence based and customized for target populations. More research is needed to determine clinical relevance of interventions and ideal interventions for specific employee groups.

Biochemical and anaplerotic applications of in vitro models of propionic acidemia and methylmalonic acidemia using patient-derived primary hepatocytes

Propionic acidemia (PA) and methylmalonic acidemia (MMA) are autosomal recessive disorders of propionyl-CoA (P-CoA) catabolism, which are caused by a deficiency in the enzyme propionyl-CoA carboxylase or the enzyme methylmalonyl-CoA (MM-CoA) mutase, respectively. The functional consequence of PA or MMA is the inability to catabolize P-CoA to MM-CoA or MM-CoA to succinyl-CoA, resulting in the accumulation of P-CoA and other metabolic intermediates, such as propionylcarnitine (C3), 3-hydroxypropionic acid, methylcitric acid (MCA), and methylmalonic acid (only in MMA). P-CoA and its metabolic intermediates, at high concentrations found in PA and MMA, inhibit enzymes in the first steps of the urea cycle as well as enzymes in the tricarboxylic acid (TCA) cycle, causing a reduction in mitochondrial energy production. We previously showed that metabolic defects of PA could be recapitulated using PA patient-derived primary hepatocytes in a novel organotypic system. Here, we sought to investigate whether treatment of normal human primary hepatocytes with propionate would recapitulate some of the biochemical features of PA and MMA in the same platform. We found that high levels of propionate resulted in high levels of intracellular P-CoA in normal hepatocytes. Analysis of TCA cycle intermediates by GC-MS/MS indicated that propionate may inhibit enzymes of the TCA cycle as shown in PA, but is also incorporated in the TCA cycle, which does not occur in PA. To better recapitulate the disease phenotype, we obtained hepatocytes derived from livers of PA and MMA patients. We characterized the PA and MMA donors by measuring key proximal biomarkers, including P-CoA, MM-CoA, as well as clinical biomarkers propionylcarnitine-to-acetylcarnitine ratios (C3/C2), MCA, and methylmalonic acid. Additionally, we used isotopically-labeled amino acids to investigate the contribution of relevant amino acids to production of P-CoA in models of metabolic stability or acute metabolic crisis. As observed clinically, we demonstrated that the isoleucine and valine catabolism pathways are the greatest sources of P-CoA in PA and MMA donor cells and that each donor showed differential sensitivity to isoleucine and valine. We also studied the effects of disodium citrate, an anaplerotic therapy, which resulted in a significant increase in the absolute concentration of TCA cycle intermediates, which is in agreement with the benefit observed clinically. Our human cell-based PA and MMA disease models can inform preclinical drug discovery and development where mouse models of these diseases are inaccurate, particularly in well-described species differences in branched-chain amino acid catabolism.

A144 A MULTIDISCIPLINARY TEAM APPROACH REDUCES PEG SITE COMPLICATIONS

Background

Education provided to patients and their family on how to care for the percutaneous enteroscopic gastrotomy (PEG) tube is limited and varies widely. This can result in site and tube complications, patient discomfort and increased health care utilization. In addition, a lack of practitioner expertise and variability in practice can affect timely treatment of PEG site complications. Continuous Levodopa/Carbidopa Intestinal Gel (LCIG) has become a standard of treatment option for patients with advanced Parkinson Disease. This medication is delivered by a jejunal tube through a PEG tube (PEG-J). Previous studies in this population reported up to 40% of adverse events related to the PEG site. At Toronto Western Hospital, we developed a multidisciplinary team (MDT), involving a gastroenterologist, a clinical nurse specialist (CNS) with expertise in wound and stoma care and the movement disorder clinical nurse to care for the PEG-J in this patient population.

Aims

To evaluate the effectiveness of our MDT in reducing PEG site complications and health care utilization.

Methods

Consecutive PEG-J patients (n=33) assessed by the MDT between October 2018 and September 2019 were provided standard education on the routine care and maintenance of PEG site complications. The CNS uses a systematic approach to prevent, assess and treat PEG site complications. Before and after the MDT approach, patients were seen the day after the PEG insertion (POD 1), 2 weeks after (titration) and then ad hoc determined by incidence of mild, moderate and severe complications. Post implementation of a MDT approach, patients are seen POD 1, at titration and every 3–6 months during routine visits to the Movement Disorder Clinic. Table 1 outlines classification and suggested treatment based on severity for mild, moderate and severe PEG site complications.

Results

The systematic MDT approach completely eliminated all unscheduled, urgent contact to the health care providers by patients who have been assessed and provided education by the MDT (n=33), including new PEG-J (n=7) and previously inserted PEG-J (n=26). 28.5% of new PEG-J patients had moderate or severe site complication rate, 71.5% had mild or no complications. In the group of patients with previously inserted PEG-J tubes, 58% had moderate or severe site complications, 42% had mild or no complications.

Conclusions

An interprofessional MDT systematic approach drastically reduces PEG site complications and urgent health care utilization. Patients who receive standardized education pre- and post-insertion have a lower incidence of moderate or severe classification of PEG site complications and unscheduled clinic visits.

Funding Agencies

None

Modified irinotecan and infusional 5-fluorouracil (mFOLFIRI) in patients with refractory advanced pancreas cancer (APC): a single-institution experience

Pancreatic adenocarcinoma is the fourth leading cause of cancer death. Recently, MM-398 (nanoliposomal irinotecan) was shown to be associated with significant improvement in outcome measures with acceptable toxicities when combined with 5-fluorouracil (5-FU)/leucovorin (LV) compared to 5-FU/LV alone in patients failing one line of gemcitabine-based therapy. There is a paucity of data evaluating the role of irinotecan in combination with 5FU in advanced pancreas cancer (APC). We performed a retrospective analysis of all patients who received mFOLFIRI (minus bolus 5FU and LV). All patients with metastatic disease who had failed at least one line of gemcitabine-based therapy prior to receiving mFOLFIRI were included in this study. Descriptive statistics were used to assess the continuous variables and adverse events (AEs), and Kaplan-Meier methods were used to calculate the median progression-free survival (PFS) and overall survival (OS). Forty patients were included in this analysis. Patients received 1-5 lines of prior therapy (25 % with more than 3 lines of prior therapy). The mean age at diagnosis was 60, and 98 % had ECOG of 1. The mean CA 19-9 at the start of therapy was 33,169 U/ml. The median PFS was 2.59 months [95 % confidence interval (CI) (1.90, 3.54)], and OS was 4.75 months [95 % CI (3.14, 8.98)]. The most common AEs included fatigue (98 %), neuropathy (83 %), anorexia (68 %), nausea (60 %) and constipation (55 %). Grade 3 toxicities included fatigue (13 %) and rash (3 %). There were no observed grade 4 toxicities. In this single-institution retrospective analysis, mFOLFIRI was found to be both tolerable and relatively effective in a heavily pretreated patient population with APC. Future prospective studies should consider evaluating the role of mFOLFIRI in refractory APC.

Pertuzumab for the treatment of patients with previously untreated HER2-positive metastatic breast cancer

Pertuzumab is a humanized monoclonal antibody directed at the dimerization domain of the receptor tyrosine-protein kinase erbB-2 (HER2) receptor. It possesses a unique and complimentary mechanism of action compared to trastuzumab, which has historically been the cornerstone of therapy for HER2-amplified breast cancer. Clinical trials demonstrate improved outcomes, with minimal increases in toxicity with the addition of pertuzumab to trastuzumab in patients with HER2-positive metastatic breast cancer, indicating the advantage of dual HER2 receptor blockade. Pertuzumab is approved as first-line therapy in combination with trastuzumab and docetaxel for HER2-positive metastatic breast cancer, with future opportunities to investigate its efficacy in other stages of breast cancer, as well as in the treatment of other malignancies.

Management of oxaliplatin-induced peripheral neuropathy

Neurotoxicity is the most frequent dose-limiting toxicity of oxaliplatin. Acute sensory neurotoxicity manifests as rapid onset of cold-induced distal dysesthesia and/or paresthesia, sometimes accompanied by cold-dependent muscular contractions of the extremities or the jaw. The symptoms, often occurring during or shortly after infusion, are usually transient and mild. A cumulative sensory peripheral neuropathy may also develop with prolonged treatment with oxaliplatin, eventually causing superficial and deep sensory loss, sensory ataxia, and functional impairment. Studies have shown patients with acute sensory symptoms to display little or no axonal degeneration. The similarity of acute symptoms induced by oxaliplatin to those caused by several drugs or toxins acting on neuronal or muscular ion channels suggests that these symptoms may result from a specific interaction of oxaliplatin with voltage-gated sodium (Na(+)) channels. The current recommendations for the management of the acute and cumulative neurotoxicity from oxaliplatin include education about exposure to cold, dose modification, "stop and go", and use of neuromodulatory agents, in particular, intravenous calcium and magnesium infusion. Upon the approval of oxaliplatin-based regimens both for adjuvant and metastatic treatment of colon cancer, it is crucial to compile knowledge about the recognition and management of neurotoxicity from oxaliplatin.

Health indicators among low income women who report a history of sex work: the population based Northern California Young Women's Survey

OBJECTIVES

We examined differences in demographic characteristics, HIV related risk behaviour, prevalence of sexually transmitted infections (STI), and HIV and other health concerns among women with and without a history of sex work.

METHODS

A secondary analysis of a population based, cross sectional survey of young, low income women in northern California.

RESULTS

Of the 2543 women interviewed, 8.9% reported a history of sex work. These women reported more lifetime male sexual partners, were more likely to use drugs before sex, and were more likely to have a history of having sex with partners at high risk for HIV (that is, men who have sex with men, inject drugs, or were known to be HIV positive). They were significantly more likely to have positive serology for syphilis, herpes simplex virus type 2 (HSV-2), and hepatitis C regardless of their personal injecting drug use history; however, they were no more likely to have HIV, chlamydia, gonorrhoea, hepatitis A or hepatitis B infection compared to women without a history of sex work. Women with a history of sex work were significantly more likely to have a history of sexual coercion and tobacco use.

CONCLUSIONS

These data measure the population prevalence of sex work among low income women and associated STI. Women with a history of sex work have health concerns beyond STI and HIV treatment and prevention.

Antineutrophil cytoplasmic antibody-associated necrotizing crescentic glomerulonephritis in a patient receiving treatment with etanercept for severe rheumatoid arthritis

Etanercept is a tumor necrosis factor inhibitor used in the treatment of rheumatoid arthritis and, increasingly, in a range of other diseases. We report a case of necrotizing crescentic glomerulonephritis, associated with a positive antineutrophil cytoplasmic antibody, causing acute renal failure in a woman receiving treatment with etanercept for severe rheumatoid arthritis. Our patient was treated with steroids and cyclophosphamide following withdrawal of etanercept, with a good clinical response. Although reports of vasculitis in patients receiving treatment with etanercept are rare, this drug has been shown to up-regulate some aspects of immune function, and the possibility that this agent may precipitate or exacerbate vasculitis in some individuals has to be considered.

Histamine poisoning associated with eating tuna burgers

CONTEXT

Histamine poisoning occurs when persons ingest fish in which bacteria have converted histidine to histamine, a process that usually can be controlled by storage at low temperatures. From 1994 to 1997, North Carolina averaged 2 cases annually; however, from July 1998 to February 1999, a total of 22 cases of histamine fish poisoning were reported.

OBJECTIVES

To examine the increase in histamine case reports, identify risk factors for poisoning, and develop recommendations for prevention.

DESIGN AND SETTING

Case series evaluated in North Carolina from July 1998 to February 1999.

SUBJECTS

Reported case-patients with 2 of the following symptoms within 2 hours of eating tuna: rash, facial flushing, vomiting, diarrhea, dyspnea, a tight feeling in the throat, headache, or a metallic or peppery taste in the mouth.

RESULTS

Twenty cases occurred during 5 outbreaks, and there were 2 single occurrences. Of the 22 persons affected, 19 (86%) sought emergency medical care. All case-patients ate tuna: 18 ate tuna burgers, 2 ate salad containing tuna, and 2 ate filets. Tuna samples (available from 3 outbreaks) had histamine levels above the Food and Drug Administration regulatory level of 50 ppm (levels were between 213 and 3245 ppm). In 19 cases, the tuna used to prepare burgers or salads was frozen and thawed more than once before serving. Violations of recommended temperature controls were identified in 2 of the 5 restaurants, accounting for 14 (64%) cases.

CONCLUSIONS

Tuna burgers, a relatively new menu item in restaurants, were associated with an increase in histamine poisoning cases in North Carolina. Tuna ground for burgers can be susceptible to both temperature fluctuations and bacterial contamination.

The history and impact of worksite wellness

Employers now pay an estimated 30% of the national health care bill. Wellness is defined as "a composite of physical, emotional, spiritual, intellectual, occupational, and social health; health promotion is the means to achieve wellness." Worksite wellness programs have developed largely in response to cost-containment efforts combined with the worksite health promotion movement. Worksite wellness efforts require the use of a model that targets reversible or alterable behaviors such as smoking, weight management, blood pressure monitoring, and stress management. Most employers in the health care arena are seen as doing too little to promote wellness among its own employees.

High flux plasma exchange using a modified rotating membrane system

The results of increasing blood flow capability in a modified system for plasma exchange with a rotating filter are reported. There were 742 treatments performed with the authors' original system (OS), limited to blood flows of 100 ml/ min, and 327 treatments performed with the updated system (US), allowing for blood flows of 150 ml/min. Blood flows for OS were 98 +/- 5 ml/min (mean +/- SD) vs 145 +/- 12 ml/min for US (p < 0.001). Plasma flows were 65 +/- 7 ml/min for OS vs 98 +/- 12 ml/min for US (p < 0.001). Plasma removal rate was 42 +/- 8 ml/min for OS vs 61 +/- 14 ml/min for US (p < 0.001). Mean treatment time was reduced from 76 +/- 23 min for OS to 52 +/- 17 min for US (p < 0.001) in spite of providing a similar amount of plasma removed per treatment (3,113 +/- 577 ml/Rx for OS vs 3078 +/- 797 ml/Rx for US; p = 0.48). Despite statistical significance, there were only small differences in filtration fractions (65 +/- 12% for OS vs 62 +/- 11% for US; p < 0.001) and patient hematocrits (34 +/- 6% for OS vs 33 +/- 6% for US; p < 0.001). In conclusion, modification of the OS to allow for increased blood flow has resulted in a substantial improvement in procedure efficiency and a clinically useful decrease in treatment time.

The effect of comprehensive outpatient pulmonary rehabilitation on dyspnea

To evaluate the effect of outpatient pulmonary rehabilitation (OPR) on dyspnea, we measured this symptom using a visual analogue scale during graded treadmill exercise testing and with baseline and transitional dyspnea indices (TDI). The latter measure overall dyspnea in three spheres: functional impairment, magnitude of task, and magnitude of effort. Twenty patients with COPD referred for OPR were randomly assigned to either a treatment group (T, n = 10), with dyspnea evaluated at baseline then shortly following a 6-week OPR program, or a control group (C, n = 10), with dyspnea evaluated at baseline then following a 6-week waiting period. No significant change in maximal exercise performance from baseline to repeated testing was observed in either group. Dyspnea at maximum treadmill workload (Dmax), which did not significantly change in C, decreased from 74.4 +/- 18.9 percent at baseline to 50.5 +/- 23.2 percent post-OPR in T (p = 0.006). The Dmax related to minute ventilation (Dmax/VEmax) and oxygen consumption (Dmax/VO2max) also significantly decreased following OPR. The reduction in exertional dyspnea was apparent by the second minute of exercise. Additionally, TDI focal scores were significantly higher in T than C (2.3 +/- 1.06 vs 0.2 +/- 1.75 units, p = 0.006), indicating decreased overall dyspnea following OPR. These results point to significant improvements in both exertional and clinically assessed dyspnea following OPR.

Are HIV-infected injection drug users taking HIV tests?

OBJECTIVES

Knowledge of infection is essential for human immunodeficiency virus-type 1 (HIV-1) treatment initiation and epidemic control. This study evaluates infection knowledge among infected injection drug users and acceptance of confidential testing among injection drug users, particularly those infected with HIV-1.

METHODS

A total of 810 injection drug users entering treatment in Contra Costa County, Calif, were examined. Clients were tested with unlinked (blinded) tests and simultaneously counseled and offered voluntary confidential HIV-1 antibody testing. Data on confidential testing acceptance, previous testing, drug use, and demographic information were collected.

RESULTS

Of the 810 tested, 105 (13.0%) were infected. The current confidential test was accepted by 507 (62.6%). HIV seroprevalence in the unlinked survey was four times greater than in the voluntary survey (13% and 3.5%, respectively). HIV-1 infection was associated with refusal of a confidential test largely because most infected injection drug users (n = 58; 55.2%) already knew of their infection. Of the 47 injection drug users who were not aware of their infection, 12 (25.5%) accepted the test. Although African-American injection drug users presented with a higher infection rate (37.3%), they were three times less likely to know of their infection.

CONCLUSIONS

"In-clinic" HIV-1 testing is highly accepted, and most infected clients in treatment will learn their status. Nevertheless, voluntary testing data are likely to yield considerable underestimates of the true rate of infection among injection drug users.

One year's experience using a rotating filter for therapeutic plasma exchange

The authors previously demonstrated the feasibility of using a rotating filter system for therapeutic plasma exchange. They now report on the technical details of a 1 year clinical experience. Seventeen patients underwent 188 treatments. Hemoaccess was provided by antecubital veins (147 Rx), femoral catheters (37 Rx), or an a-v fistula (3 Rx). Blood flows ranged from 75 to 100 ml/min. Net plasma removed per treatment was 3,231 +/- 53 ml (mean +/- SE, n = 188). Mean plasma removal rate per treatment was 40.2 +/- 0.6 ml/min; mean treatment time was 83 +/- 2 min. Platelet counts before and after treatment revealed a 15 +/- 4% decline (n = 46 Rx). Despite filtration fractions up to 86% there was no evidence of significant membrane plugging or hemolysis. For semiselective removal of cholesterol, the rotating filter was used in a cascade system with a secondary filter. Eighty percent of processed plasma was returned to the patient, but the treatment time was prolonged by 37% and the total cholesterol removed was 26% less when compared with the single pass system. The authors conclude that an inexpensive rotating filter can provide a highly efficient plasma exchange. The inherent efficiency of this system must be considered when evaluating its use with secondary filtration techniques.

Spinal stress-an approach to quantification with respect to back pain

Back pain is a major problem throughout the industrialized world, and although its aetiology is ill understood, the problem demands immediate attention. This paper briefly describes the investigative strategy used in studies of back pain by the Ergonomics Research Unit at the University of Surrey. It then concentrates on the biomechanical perspective of spinal stress and by means of two studies, one based in the field the other in the laboratory, illustrates methods including an ambulatory monitoring and computer analysis system for intra-abdominal pressure, trunk inclination and physiological data, and subjective assessments. The objective of these methods is to quantify the risk factors associated with back pain, thereby allowing changes to be made with respect to equipment, environments and tasks within the workplace. Finally, the need to evaluate such changes scientifically is emphasized.

Interocular transfer of the motion after-effect in normal and stereoblind observers

The extent of interocular transfer of the motion after-effect was measured in 4 stereoblind subjects and in 19 subjects having varying degrees of stereopsis. Stereoblind individuals failed completely to show any interocular transfer of this after-effect, while subjects with good stereopsis exhibited between 55 and 82 percent transfer (mean 73 percent). Furthermore, normal subjects who manifested a clear eye dominance tended to show greater transfer from the dominant to the nondominant eye than vice versa. Individuals who either had a history of a strabismus or possessed some other early impediment to clear binocular vision tended to show less transfer. Overall there was a significant positive correlation of 0.75 between the extent of interocular transfer and the subject's stereoacuity. It is argued that the extent of interocular transfer of this after-effect provides a measure of the proportion of the total number of visual cortical neurons that are binocular. Thus stereoblind humans, who show no transfer whatsoever may, like cats and monkeys deprived of concordant binocular visual input early in life, suffer from a lack of binocular neurons.