Are Patient Demographics and Payor Status Associated With Practice Patterns in the Surgical Management of Carpal Tunnel Syndrome?

BACKGROUND

Open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR) are the 2 operative approaches used to treat carpal tunnel syndrome (CTS). This study aims to identify whether differences between OCTR and ECTR rates exist, and, if so, are these differences associated with patient demographics or hospital characteristics.

METHODS

The 2018 Nationwide Ambulatory Surgery Sample (NASS) was filtered for patient encounters including either OCTR or ECTR operations. All patients undergoing either OCTR or ECTR were included, regardless of surgical specialty. Patient demographics and hospital characteristics data, provided and predefined by the NASS database, were collected and compared between the 2 treatment groups.

RESULTS

A total of 180 740 patient encounters were collected for both procedure types (OCTR: 62.4% women, mean age, 58 years; ECTR: 62.2% women, mean age, 58 years). Patients from lower income zip codes were more likely to undergo OCTR (P < .001). Patients either self-paying (P < .008) or covered by Medicare (P < .001) or Medicaid insurance (P < .001) were also more likely to undergo OCTR. In contrast, patients who received care at academic centers and centers with >300 beds were more likely to undergo ECTR (P < .001). Patients <65 years old were more likely to undergo ECTR (P < .001), and patients > 75 years old were more likely to undergo OCTR (P < .001). In addition, ECTR was found to be more expensive, with average total charges $1568 greater than charges for OCTR (P < .001).

CONCLUSIONS

Significant differences exist in treatment strategies for CTS and are related to patient income, location, and primary payor status. Differences in OCTR and ECTR rates are also present, and are related to the size and academic status of hospitals.

Trends in firearm production and firearm deaths in U.S. youth

INTRODUCTION

Firearms are now the leading cause of death for U.S. children and teens ages 0-19. The U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) reported data in 2022 on firearm production, for specific firearm types and calibers. We hypothesized there would be a correlation between firearm production and firearm deaths and nonfatal injuries in youth.

METHODS

All firearm deaths and nonfatal injury rates for youth ages 0-19 were extracted from the Centers for Disease Control and Prevention from 2001 to 2020. Firearm production from 2001 to 2020 was extracted from the 2022 ATF Firearms in Commerce Report for overall firearm production, production by weapon type and pistol caliber. Relationships between firearm death and injury and firearm production were evaluated using correlational analyses.

RESULTS

Firearm death and nonfatal injury rates for youth increased from 2001 to 2020 by 48.2% and 69.2%, respectively, and firearm production increased 265% overall and 1298% for 9 mm pistols. There was no correlation between total firearm manufacturing and total firearm deaths or nonfatal injury rates from 2001 to 2020 (all r < 0.28). Pistol caliber (25 and 9 mm) was associated with total firearm deaths and nonfatal injuries (all r > 0.55).

CONCLUSION

While total firearm manufacturing was not related to firearm deaths and injuries, except suicides, there were strong relationships between 9 mm pistol production and firearm deaths and injuries in youth. Firearm injuries are preventable; we must invest in stronger information systems that track details of firearms linked with deaths and injuries.

Abnormal Mechanics Relate to Myocardial Fibrosis and Ventricular Arrhythmias in Patients With Mitral Valve Prolapse

BACKGROUND

The relation between ventricular arrhythmia and fibrosis in mitral valve prolapse (MVP) is reported, but underlying valve-induced mechanisms remain unknown. We evaluated the association between abnormal MVP-related mechanics and myocardial fibrosis, and their association with arrhythmia.

METHODS

We studied 113 patients with MVP with both echocardiogram and gadolinium cardiac magnetic resonance imaging for myocardial fibrosis. Two-dimensional and speckle-tracking echocardiography evaluated mitral regurgitation, superior leaflet and papillary muscle displacement with associated exaggerated basal myocardial systolic curling, and myocardial longitudinal strain. Follow-up assessed arrhythmic events (nonsustained or sustained ventricular tachycardia or ventricular fibrillation).

RESULTS

Myocardial fibrosis was observed in 43 patients with MVP, predominantly in the basal-midventricular inferior-lateral wall and papillary muscles. Patients with MVP with fibrosis had greater mitral regurgitation, prolapse, and superior papillary muscle displacement with basal curling and more impaired inferior-posterior basal strain than those without fibrosis (P<0.001). An abnormal strain pattern with distinct peaks pre-end-systole and post-end-systole in inferior-lateral wall was frequent in patients with fibrosis (81 versus 26%, P<0.001) but absent in patients without MVP with basal inferior-lateral wall fibrosis (n=20). During median follow-up of 1008 days, 36 of 87 patients with MVP with >6-month follow-up developed ventricular arrhythmias associated (univariable) with fibrosis, greater prolapse, mitral annular disjunction, and double-peak strain. In multivariable analysis, double-peak strain showed incremental risk of arrhythmia over fibrosis.

CONCLUSIONS

Basal inferior-posterior myocardial fibrosis in MVP is associated with abnormal MVP-related myocardial mechanics, which are potentially associated with ventricular arrhythmia. These associations suggest pathophysiological links between MVP-related mechanical abnormalities and myocardial fibrosis, which also may relate to ventricular arrhythmia and offer potential imaging markers of increased arrhythmic risk.

Sauvé-Kapandji and Darrach Salvage Procedure Rates and Perioperative Parameters for Distal Radioulnar Joint Arthritis and Instability

BACKGROUND

Distal radioulnar joint (DRUJ) instability and arthritis are often painful and functionally limiting pathologies. Two common salvage procedures for DRUJ dysfunction are the Darrach and Sauvé-Kapandji (S-K) procedures. This study aims to provide an analysis of national Darrach and S-K procedure utilization rates and patient demographics.

METHODS

A national ambulatory surgery database, the 2018 Nationwide Ambulatory Surgery Sample, was filtered for Darrach and S-K procedure encounters. Data related to patient demographics and medical history, indications for DRUJ salvage, and concurrent hand/wrist procedures were collected.

RESULTS

Database analysis revealed 1044 Darrach and 223 S-K procedure encounters. Patients undergoing Darrach procedures were older (60 vs 57, P = .002) and more likely to be women (66.1% vs 54.6%, P < .05). Patients aged <35 years underwent S-K procedures at greater rates compared with Darrach (13.9% vs 8.6%, P < .05). Primary osteoarthritis proved to be the most common indication for DRUJ salvage (64.8%) compared with rheumatoid arthritis (23.2%) and post-traumatic osteoarthritis (12.0%). Darrach and S-K procedures were accompanied by a secondary procedure at rates of 64% and 41%, respectively. The most common secondary procedures were tendon transfer, implant removal, neuroplasty, nerve resections, and wrist arthroscopy.

CONCLUSIONS

Patient age and sex are associated with DRUJ salvage procedure selection. Sauvé-Kapandji procedures are used in higher rates in male and younger patient populations. Furthermore, primary osteoarthritis and rheumatoid arthritis are the main underlying pathologies for Darrach and S-K procedures.

Patterns in Academic Cosmetic Surgery Practice: Population Differences and Procedure Preferences

PURPOSE

Although growth in cosmetic surgery remains constant in the private setting, academic cosmetic surgery practices are often underdeveloped. Our study aims to determine which patient populations access academic cosmetic surgery services.

METHODS

The 2018 Health Care Utilization Project Nationwide Ambulatory Surgery Sample database was used for data analysis. Encounters for the following American Society of Plastic Surgery top 5 procedures for 2020 were selected: blepharoplasty, breast augmentation, liposuction, rhinoplasty, and rhytidectomy. Patient encounter data were collected because it relates to median income, geographic location, and primary payer status.

RESULTS

The 2018 Nationwide Ambulatory Surgery Sample data set contained 44,078 encounters at academic surgical centers for the procedures listed previously. Low-income patients account for 13.7% of academic cosmetic surgery encounters compared with 37.9% for high-income patients. Breast augmentation rates are higher among low-income patients (20.5% vs 17.2%, P < 0.001), and high-income patients undergo rhytidectomy more frequently (5.7% vs 3.0%, P < 0.001). In the academic setting, patients from large metropolitan areas encompass the majority of cosmetic encounters (71.0%), and these patients are more likely to proceed with rhinoplasty, rhytidectomy, and liposuction procedures (P < 0.001). Patients from smaller metropolitan areas undergo blepharoplasty more frequently compared with those from larger metropolitan areas (56.4% vs 41.8%, P < 0.001). Self-pay and privately insured patients comprise the majority of academic cosmetic surgery encounters (40.8% and 29.9%, respectively). Eighty-eight percent of Medicare patients within this cohort underwent blepharoplasty, whereas self-pay patients accessed breast augmentation, liposuction, and rhytidectomy more often than other insured patients.

CONCLUSIONS

Income status, patient location, and primary payer status play an important role in academic cosmetic surgery access rates and procedure preferences. Academic cosmetic practices can use these insights to tailor their services to the populations they serve.

High-precision measurement of the W boson mass with the CDF II detector

The mass of the W boson, a mediator of the weak force between elementary particles, is tightly constrained by the symmetries of the standard model of particle physics. The Higgs boson was the last missing component of the model. After observation of the Higgs boson, a measurement of the W boson mass provides a stringent test of the model. We measure the W boson mass, M_W, using data corresponding to 8.8 inverse femtobarns of integrated luminosity collected in proton-antiproton collisions at a 1.96 tera-electron volt center-of-mass energy with the CDF II detector at the Fermilab Tevatron collider. A sample of approximately 4 million W boson candidates is used to obtain [Formula: see text], the precision of which exceeds that of all previous measurements combined (stat, statistical uncertainty; syst, systematic uncertainty; MeV, mega-electron volts; c, speed of light in a vacuum). This measurement is in significant tension with the standard model expectation.

Metallosis following hip arthroplasty: two case reports

Background

There has been increasing recognition of local and systemic adverse events associated with the release of metal ions and nanoparticles from hip arthroplasty components. Adverse local tissue reactions to metal ion debris can include periprosthetic solid and cystic masses known as pseudotumors. These masses can result in pain, swelling, extensive destruction to surrounding hip soft-tissues, and compression syndromes on neurovascular, gastrointestinal, and genitourinary structures. As reports of pseudotumors requiring multidisciplinary excision are limited, we present two pseudotumor cases that were excised through a combined approach.

Case presentations

The first case involves a 60-year-old Caucasian female with a large pseudotumor with intrapelvic and vascular involvement associated with a metal-on-polyethylene total hip arthroplasty, excised with contributions from general surgery, vascular surgery, and orthopedic surgery. Pseudotumor excision was followed by a revision total hip reconstruction in addition to an abductor mechanism reconstruction with tendo-Achilles allograft. The second case is that of a 64-year-old Caucasian female with a pseudotumor in close relationship to the femoral vessels following a metal-on-metal hip resurfacing, excised with a combination of vascular surgery and orthopedic surgery, with subsequent revision total hip reconstruction.

Conclusions

There remains a lack of literature to support the extensiveness of pseudotumor excision required in complex cases with significant intrapelvic or vascular involvement. Given the potential for significant adverse effects of large masses, the authors’ preference is to involve a multidisciplinary team to achieve a more comprehensive excision while minimizing the risk of potential complications.

Innovation in regulatory approaches for endocrine disrupting chemicals: The journey to risk assessment modernization in Canada

Globally, regulatory authorities grapple with the challenge of assessing the hazards and risks to human and ecosystem health that may result from exposure to chemicals that disrupt the normal functioning of endocrine systems. Rapidly increasing number of chemicals in commerce, coupled with the reliance on traditional, costly animal experiments for hazard characterization - often with limited sensitivity to many important mechanisms of endocrine disruption -, presents ongoing challenges for chemical regulation. The consequence is a limited number of chemicals for which there is sufficient data to assess if there is endocrine toxicity and hence few chemicals with thorough hazard characterization. To address this challenge, regulatory assessment of endocrine disrupting chemicals (EDCs) is benefiting from a revolution in toxicology that focuses on New Approach Methodologies (NAMs) to more rapidly identify, prioritize, and assess the potential risks from exposure to chemicals using novel, more efficient, and more mechanistically driven methodologies and tools. Incorporated into Integrated Approaches to Testing and Assessment (IATA) and guided by conceptual frameworks such as Adverse Outcome Pathways (AOPs), emerging approaches focus initially on molecular interactions between the test chemical and potentially vulnerable biological systems instead of the need for animal toxicity data. These new toxicity testing methods can be complemented with in silico and computational toxicology approaches, including those that predict chemical kinetics. Coupled with exposure data, these will inform risk-based decision-making approaches. Canada is part of a global network collaborating on building confidence in the use of NAMs for regulatory assessment of EDCs. Herein, we review the current approaches to EDC regulation globally (mainly from the perspective of human health), and provide a perspective on how the advances for regulatory testing and assessment can be applied and discuss the promises and challenges faced in adopting these novel approaches to minimize risks due to EDC exposure in Canada, and our world.

DCHS1, Lix1L, and the Septin Cytoskeleton: Molecular and Developmental Etiology of Mitral Valve Prolapse

Mitral valve prolapse (MVP) is a common cardiac valve disease that often progresses to serious secondary complications requiring surgery. MVP manifests as extracellular matrix disorganization and biomechanically incompetent tissues in the adult setting. However, MVP has recently been shown to have a developmental basis, as multiple causal genes expressed during embryonic development have been identified. Disease phenotypes have been observed in mouse models with human MVP mutations as early as birth. This study focuses on the developmental function of DCHS1, one of the first genes to be shown as causal in multiple families with non-syndromic MVP. By using various biochemical techniques as well as mouse and cell culture models, we demonstrate a unique link between DCHS1-based cell adhesions and the septin-actin cytoskeleton through interactions with cytoplasmic protein Lix1-Like (LIX1L). This DCHS1-LIX1L-SEPT9 axis interacts with and promotes filamentous actin organization to direct cell-ECM alignment and valve tissue shape.

Color Doppler Ultrasound versus Computed Tomography Angiography for Preoperative Anterolateral Thigh Flap Perforator Imaging: A Systematic Review and Meta-Analysis

BACKGROUND

 The anterolateral thigh (ALT) perforator flap is a commonly used flap with a predictable, though often variable, perforator anatomy. Preoperative imaging with color Doppler ultrasound (CDU) and computed tomography angiography (CTA) of ALT flap perforators can be a useful tool for flap planning. This study provides a complete review and analysis of the relevant preoperative ALT imaging literature.

METHODS

 Studies related to preoperative CDU and CTA imaging were reviewed, and information related to imaging method, sensitivity, false-positive rates, and perforator course identification (musculocutaneous vs. septocutaneous) were analyzed.

RESULTS

 A total of 23 studies related to preoperative ALT flap CDU and CTA imaging were included for review and analysis. Intraoperative perforator identification was compared with those found preoperatively using CDU (n = 672) and CTA (n = 531). Perforator identification sensitivity for CDU was 95.3% (95% CI: 90.9-97.6%) compared with the CTA sensitivity of 90.4% (95% confidence interval [CI]: 74.4-96.9%). The false-positive rate for CDU was 2.8% (95% CI: 1.1-4.5%) compared with 2.4% (95% CI: 0.7-4.1%) for CTA. Accuracy of perforator course identification was 95.5% (95% CI: 93.6-99.2%) for CDU and 96.9% (95% CI: 92.7-100.1%) for CTA.

CONCLUSION

 CDU provides the reconstructive surgeon with greater preoperative perforator imaging sensitivity compared with CTA; however, false-positive rates are marginally higher with preoperative CDU. Preoperative imaging for ALT flap design is an effective tool, and the reconstructive surgeon should consider the data presented here when selecting a flap imaging modality.

Mitral Valve Prolapse Induces Regionalized Myocardial Fibrosis

Background Mitral valve prolapse (MVP) is one of the most common forms of cardiac valve disease and affects 2% to 3% of the population. Previous imaging reports have indicated that myocardial fibrosis is common in MVP and described its association with sudden cardiac death. These data combined with evidence for postrepair ventricular dysfunction in surgical patients with MVP support a link between fibrosis and MVP. Methods and Results We performed histopathologic analysis of left ventricular (LV) biopsies from peripapillary regions, inferobasal LV wall and apex on surgical patients with MVP, as well as in a mouse model of human MVP (Dzip1S14R/+). Tension-dependent molecular pathways were subsequently assessed using both computational modeling and cyclical stretch of primary human cardiac fibroblasts in vitro. Histopathology of LV biopsies revealed regionalized fibrosis in the peripapillary myocardium that correlated with increased macrophages and myofibroblasts. The MVP mouse model exhibited similar regional increases in collagen deposition that progress over time. As observed in the patient biopsies, increased macrophages and myofibroblasts were observed in fibrotic areas within the murine heart. Computational modeling revealed tension-dependent profibrotic cellular and molecular responses consistent with fibrosis locations related to valve-induced stress. These simulations also identified mechanosensing primary cilia as involved in profibrotic pathways, which was validated in vitro and in human biopsies. Finally, in vitro stretching of primary human cardiac fibroblasts showed that stretch directly activates profibrotic pathways and increases extracellular matrix protein production. Conclusions The presence of prominent regional LV fibrosis in patients and mice with MVP supports a relationship between MVP and progressive damaging effects on LV structure before overt alterations in cardiac function. The regionalized molecular and cellular changes suggest a reactive response of the papillary and inferobasal myocardium to increased chordal tension from a prolapsing valve. These studies raise the question whether surgical intervention on patients with MVP should occur earlier than indicated by current guidelines to prevent advanced LV fibrosis and potentially reduce residual risk of LV dysfunction and sudden cardiac death.

DZIP1 regulates mammalian cardiac valve development through a Cby1-β-catenin mechanism

Background

Mitral valve prolapse (MVP) is a common and progressive cardiovascular disease with developmental origins. How developmental errors contribute to disease pathogenesis are not well understood.

Results

A multimeric complex was identified that consists of the MVP gene Dzip1, Cby1, and β‐catenin. Co‐expression during valve development revealed overlap at the basal body of the primary cilia. Biochemical studies revealed a DZIP1 peptide required for stabilization of the complex and suppression of β‐catenin activities. Decoy peptides generated against this interaction motif altered nuclear vs cytosolic levels of β‐catenin with effects on transcriptional activity. A mutation within this domain was identified in a family with inherited non‐syndromic MVP. This novel mutation and our previously identified DZIP1^S24R variant resulted in reduced DZIP1 and CBY1 stability and increased β‐catenin activities. The β‐catenin target gene, MMP2 was up‐regulated in the Dzip1^S14R/+ valves and correlated with loss of collagenous ECM matrix and myxomatous phenotype.

Conclusion

Dzip1 functions to restrain β‐catenin signaling through a CBY1 linker during cardiac development. Loss of these interactions results in increased nuclear β‐catenin/Lef1 and excess MMP2 production, which correlates with developmental and postnatal changes in ECM and generation of a myxomatous phenotype.

PDGFRα: Expression and Function during Mitral Valve Morphogenesis

Mitral valve prolapse (MVP) is a common form of valve disease and can lead to serious secondary complications. The recent identification of MVP causal mutations in primary cilia-related genes has prompted the investigation of cilia-mediated mechanisms of disease inception. Here, we investigate the role of platelet-derived growth factor receptor-alpha (PDGFRα), a receptor known to be present on the primary cilium, during valve development using genetically modified mice, biochemical assays, and high-resolution microscopy. While PDGFRα is expressed throughout the ciliated valve interstitium early in development, its expression becomes restricted on the valve endocardium by birth and through adulthood. Conditional ablation of Pdgfra with Nfatc1-enhancer Cre led to significantly enlarged and hypercellular anterior leaflets with disrupted endothelial adhesions, activated ERK1/2, and a dysregulated extracellular matrix. In vitro culture experiments confirmed a role in suppressing ERK1/2 activation while promoting AKT phosphorylation. These data suggest that PDGFRα functions to suppress mesenchymal transformation and disease phenotypes by stabilizing the valve endocardium through an AKT/ERK pathway.

Micro-elimination of hepatitis C among people with HIV coinfection: declining incidence and prevalence accompanying a multi-center treatment scale-up trial

BACKGROUND

Gay and bisexual men (GBM) are a key population affected by HIV and hepatitis C (HCV) co-infection. Providing HCV treatment scale-up across specialist and non-hepatitis specialist settings may eliminate HCV in this population. We aimed to (1) deliver and measure HCV treatment effectiveness, and (2) determine the population impact of treatment on HCV prevalence and incidence longitudinally.

METHODS

The co-EC Study (Enhancing care and treatment among HCV/HIV co-infected individuals to Eliminate Hepatitis C transmission) was an implementation trial providing HCV direct-acting antiviral treatment in Melbourne, Australia, from 2016-2018. Individuals with HCV/HIV co-infection were prospectively enrolled from primary and tertiary-care services providing care for 85% of GBM with HIV in our jurisdiction. HCV-viraemic prevalence and HCV-antibody/viraemic incidence were measured using a state-wide, individually-linked, electronic surveillance system.

RESULTS

Among 200 participants recruited, 186 initiated treatment during the study period. Sustained virological response among primary care participants (98%, 95%CI:93-100%) was not different to tertiary care (98%, 95%CI:86-100%). From 2012-2019, between 2434 and 3476 GBM with HIV-infection attended our primary-care sites annually providing 13,801 person-years of follow-up; 50-60% received an HCV test annually, 10-14% were anti-HCV positive. Among those anti-HCV positive, viraemic prevalence declined 83% during the study (54% to 9%; 2016 to 2019). HCV incidence decreased 25% annually from 1.7/100 person-years in 2012 to 0.5/100 person-years in 2019 (incidence rate ratio 0.75; CI:0.68-0.83;p<0.001).

CONCLUSION

High treatment effectiveness by non-specialists demonstrates the feasibility of treatment scale-up in this population. Substantial declines in HCV incidence and prevalence among GBM with HIV-infection provides proof-of-concept for HCV micro-elimination.

REGISTRATION

ClinicalTrials.gov (Identifier: NCT02786758).

Effect of successive endoscopic procedures in polyp and adenoma detection rates: Too early is not always too good

BACKGROUND AND AIMS: There is conflicting evidence regarding the impact of hypothetical cumulative fatigue after performing too many endoscopic procedures on both polyp and adenoma detection rates (PDR, and ADR, respectively). The aim of this study is to evaluate the effect of successive endoscopic procedures on PDR and ADR.

METHODS

A retrospective cross-sectional study was undertaken among consecutive patients on whom colonoscopy and/or esophagogastroduodenoscopy were performed between January 2012 and August 2014. Data regarding polyp and adenoma detection, cecal intubation, and bowel cleansing quality as well as demographical data of subjects were extracted. Endoscopic procedures were classified according to the time slots of the procedures throughout the endoscopy session in three groups: from the 1st to 4th endoscopy study (round 1), from the 5th to the 8th study (round 2), above the 9th study (round 3). We compared PDR and ADR among rounds.

RESULTS

Overall, 3388 patients were enrolled. Median age was 50 years (range 18-95) and 52.39% were female. There was a significant difference in terms of PDR among rounds (36.83%, 41.24%, and 43.38%, respectively, p = 0.007) and a non-significant numerical difference when ADR was compared (23.2%, 25.71%, and 26.78%, p = 0.07). On multivariate analysis, ADR was significantly associated with age (odds ratio [OR] 1.02 [1.01-1.03]), and male sex (OR 1.64 [1.38-1.94]).

CONCLUSION

Theoretical endoscopist's fatigue due to cumulative performance of endoscopies does not diminish colonoscopy quality. Both PDR and ADR seem to improve after endoscopist's cumulative rounds of performed endoscopies. This could be due to a "warm-up" effect.

Where is the 'wisdom' in wisdom tooth surgery? A review of national and international third molar surgery guidelines

The objective of this narrative review was to identify and evaluate published international guidelines on mandibular third molars (M3M) and to assess their clinical scope and the validity of the recommendations. The search strategy used data obtained from a variety of sources including MEDLINE, national regulatory bodies, national dental and surgical colleges and associations, and military medical departments. Adherence to clinical guideline development was investigated using the AGREE II instrument (Appraisal of Guidelines for Research and Evaluation). Sixteen guidelines pertaining to M3M were included in this review. The guidelines produced by the Faculty of Dental Surgery of the Royal College of Surgeons of England (FDS RCS) and Scottish Intercollegiate Guidelines Network (SIGN) were recommended as meeting the criteria for use. Seven other guidelines were recommended but required modifications. The AGREE II instrument provides an excellent framework for guideline assessment. Unfortunately, very few guidelines scored highly across all domains and therefore were not believed to be of high quality. Due to the significant lack of structure and variable standards in guideline development, the conclusions and recommendations of these guidelines are compromised. There is a need for organizations involved in developing M3M guidelines to update guidance periodically in order to ensure that the information available to clinicians and patients is accurate and relevant to clinical practice.

Dynamic Expression Profiles of β-Catenin during Murine Cardiac Valve Development

β-catenin has been widely studied in many animal and organ systems across evolution, and gain or loss of function has been linked to a number of human diseases. Yet fundamental knowledge regarding its protein expression and localization remains poorly described. Thus, we sought to define whether there was a temporal and cell-specific regulation of β-catenin activities that correlate with distinct cardiac morphological events. Our findings indicate that activated nuclear β-catenin is primarily evident early in gestation. As development proceeds, nuclear β-catenin is down-regulated and becomes restricted to the membrane in a subset of cardiac progenitor cells. After birth, little β-catenin is detected in the heart. The co-expression of β-catenin with its main transcriptional co-factor, Lef1, revealed that Lef1 and β-catenin expression domains do not extensively overlap in the cardiac valves. These data indicate mutually exclusive roles for Lef1 and β-catenin in most cardiac cell types during development. Additionally, these data indicate diverse functions for β-catenin within the nucleus and membrane depending on cell type and gestational timing. Cardiovascular studies should take into careful consideration both nuclear and membrane β-catenin functions and their potential contributions to cardiac development and disease.

Abstract MP173: Loss of DCHS1 Promotes Mitral Valve Prolapse Through Cytoskeleton Destabilization

Introduction: Mitral valve prolapse (MVP) is a major source of morbidity and mortality and is becoming one of the most common indications for cardiac surgery. Our group has previously reported that MVP is associated with missense mutations in DCHS1 , a gene widely implicated in tissue development and organization.

Purpose: We recently performed two-hybrid screens and co-immunoprecipitation assays that define a novel complex between DCHS1, LIX1L, and SEPT9 (DLS). Our current studies investigate the role of this interaction in mitral valve morphogenesis.

Methods: Wild-type (WT), DCHS1, and/or LIX1L heterozygous neonate murine heart tissue was isolated for primary culture of cardiac fibroblasts (CFs) and analyzed with immunocytochemistry, collagen, compaction, fibrin pillar to post assays, and actin sedimentation assays. Nuclear morphology and chromatin density were conducted for functional read-outs of cytoskeletal aberrations. Morphologic and functional analyses of murine mitral valves were completed.

Results: Loss of actin architecture and collagen compaction capability were seen in CFs deficient of DCHS1 and/or LIX1L. Delivery of a peptide that disrupted the LIX1L-SEPT9 binding domain likewise destroyed actin architecture and reduced ECM compaction. In-vivo epistasis studies support these findings as mitral valve enlargement was exacerbated in DCHS1/LIX1L compound heterozygote mice compared to DCHS1 and LIX1L heterozygotes. Echocardiography of 11-month DCHS1/LIX1L compound heterozygote mice revealed pronounced MVP and increased left atrium diameter relative to DCHS1 and LIX1L heterozygotes. Filamentous SEPTIN9 localized to the actin ultrastructure and was also lost with disturbance of the DLS complex. Nuclei stretch and chromatin compaction were reduced in DCHS1/LIX1L compound heterozygote CFs. Further, histone H4 modifications were observed in DCHS1 KO mouse embryonic fibroblasts that indicate reductions in gene expression.

Conclusion: DCHS1, through its interaction with the septin cytoskeleton, must regulate and stabilize actin dynamics in mitral VICs leading to proper valve development. Non-surgical interventions for MVP may be identified through establishing the downstream effects of DCHS1 mutations in our model.

Primary cilia defects causing mitral valve prolapse

Mitral valve prolapse (MVP) affects 1 in 40 people and is the most common indication for mitral valve surgery. MVP can cause arrhythmias, heart failure, and sudden cardiac death, and to date, the causes of this disease are poorly understood. We now demonstrate that defects in primary cilia genes and their regulated pathways can cause MVP in familial and sporadic nonsyndromic MVP cases. Our expression studies and genetic ablation experiments confirmed a role for primary cilia in regulating ECM deposition during cardiac development. Loss of primary cilia during development resulted in progressive myxomatous degeneration and profound mitral valve pathology in the adult setting. Analysis of a large family with inherited, autosomal dominant nonsyndromic MVP identified a deleterious missense mutation in a cilia gene, DZIP1 A mouse model harboring this variant confirmed the pathogenicity of this mutation and revealed impaired ciliogenesis during development, which progressed to adult myxomatous valve disease and functional MVP. Relevance of primary cilia in common forms of MVP was tested using pathway enrichment in a large population of patients with MVP and controls from previously generated genome-wide association studies (GWAS), which confirmed the involvement of primary cilia genes in MVP. Together, our studies establish a developmental basis for MVP through altered cilia-dependent regulation of ECM and suggest that defects in primary cilia genes can be causative to disease phenotype in some patients with MVP.

SAT-436 Long-Term Analysis of Weight Change Following Thyroidectomy

Introduction: Weight gain is a common source of apprehension for patients undergoing thyroidectomy. However, contradictory reports exist regarding the presence and degree of weight gain following thyroid surgery and all known studies have short term follow-up This study evaluated weight changes following total thyroidectomy (TT) and lobectomy (L) over an extended time period. Methods: Retrospective analysis was performed of weight changes following surgery for patients who underwent TT or L (n=387) as compared with those undergoing parathyroidectomy for primary hyperparathyroidism (n=201) in a tertiary referral hospital between 2007-2012. Clinical, demographic and pre- and postoperative weight data was collected with a median follow-up of 55.6 months. Results: Postoperative weight change was observed at 1, 6, 12, and 36-months in patients who underwent TT (μ=+0.21kg, μ=+1.33kg, μ=+0.59kg, μ=+0.60kg; p<0.05) and at 6-months for patients who underwent L (μ=+0.93kg, p<0.05) compared with those who underwent parathyroidectomy. Patients having TT and L showed a general trend of weight gain compared to the control group up to 108-months post-operation; however, this weight gain was non-significant (p<0.05). Significant postoperative weight gain was observed in patients who had TT (1-month μ=+0.40kg, 6-months μ=+2.14kg, and 12-months μ=+1.40kg) and L (6-months μ=+1.04kg) for benign conditions compared with the parathyroidectomy group. Patients who had TT gained 0.40kg more than L patients at 12-months post-op (p<0.05), but no significant difference existed at other time points up to 108-months. Tukey HSD post-hoc analysis showed weight gain in benign, thyroiditis, and thyroid cancer patient groups was not significantly different from 6-months to 108-months post-operation. Furthermore, neither race nor sex was correlated with weight gain. Relative risks with 95% CI for weight gain following TT and L compared to control are: 1-month TT=1.74, 0.96-3.14, L=1.59, 0.58-2.58; 6-month TT=1.27, 0.85-1.89, L=1.42, 0.85-2.11; 12-month TT=1.44, 0.92-2.28, L=1.34, 0.86-2.36; 24-month TT=1.17, 0.82-1.67, L=1.22, 0.69-1.60. In the group of patients who gained greater than 2kg, those who underwent TT had significant weight increase compared to the parathyroidectomy group at 6-months postoperatively (Mann-Whitney U, p=0.011). In the subgroup of patients with weight gain greater than 2kg, those who had L did not have significant weight increase at any time point. Conclusion: Weight change following TT when compared with parathyroidectomy is significant shortly after surgery. However, these changes are not significant at long-term follow-up.

Prion protein N1 cleavage peptides stimulate microglial interaction with surrounding cells

Microglia act as the protective immune cell of the brain. By surveying the tissue to identify and rectify problems, they function to maintain the health of brain cells. The prion protein N-terminal cleavage fragment, N1, has demonstrated neuroprotective activities in vitro and in vivo. This study aimed to elucidate whether N1 could modulate microglial function and, if so, determine the consequences for the surrounding tissue. Using a mixed neuronal lineage and microglia co-culture system, we showed that N1 stimulation changed overall morphology and metabolism, suggesting enhanced cellular viability. Furthermore, N1 induced an increase in Cxcl10 secretion in the co-cultures. Recombinant Cxcl10, administered exogenously, mediated the changes in the mixed neuronal lineage culture morphology and metabolism in the absence of microglia, but no effect of Cxcl10 was observed on microglia cultured on their own. Direct cell-to-cell contact was required for N1 to influence microglia in the co-cultures, and this was linked with restructuring of microglial membrane composition to include a higher GM1 content at interaction sites with surrounding cells. Our findings show that N1 can play a regulatory role in microglial function in the context of an inter-connected network of cells by changing both cellular interaction sites and cytokine secretion.

Desert hedgehog-primary cilia cross talk shapes mitral valve tissue by organizing smooth muscle actin

Non-syndromic mitral valve prolapse (MVP) is the most common heart valve disease affecting 2.4% of the population. Recent studies have identified genetic defects in primary cilia as causative to MVP, although the mechanism of their action is currently unknown. Using a series of gene inactivation approaches, we define a paracrine mechanism by which endocardially-expressed Desert Hedgehog (DHH) activates primary cilia signaling on neighboring valve interstitial cells. High-resolution imaging and functional assays show that DHH de-represses smoothened at the primary cilia, resulting in kinase activation of RAC1 through the RAC1-GEF, TIAM1. Activation of this non-canonical hedgehog pathway stimulates α-smooth actin organization and ECM remodeling. Genetic or pharmacological perturbation of this pathway results in enlarged valves that progress to a myxomatous phenotype, similar to valves seen in MVP patients. These data identify a potential molecular origin for MVP as well as establish a paracrine DHH-primary cilium cross-talk mechanism that is likely applicable across developmental tissue types.

Comparison of the Results of CAPD Treatment in “Experienced” versus “Inexperienced” Centres in Europe

Five per cent of almost 80,000 living patients with end stage renal failure (ESRF) in Europe were on CAPD on 31st December, 1982. The use of CAPD has grown dramatically since 1977. Centres which reported the use of CAPD to the EDTA Registry were divided into “experienced” and “inexperienced.” Patients treated in “experienced” centres had less peritonitis and spent less time in hospital because of peritonitis. Patient survival amongst those starting treatment in earlier years was worse in the “inexperienced” centres but improved so that it equalled survival in the “experienced” centres in 1982. At 12 months cumulative patient survival in patients commencing CAPD in 1982 was 87% and technique survival exceeded 95%. It appears that there is now a homogenous population of centres with approximately equal expertise.

The Demography of CAPD in Europe

Five per cent of European patients on therapy for end stage renal failure and reported to the EDTA Registry were treated by CAPD on 31st December, 1982. The percentage varied between 12.7% in the United Kingdom to less than 1% in Eastern European countries. In the total area covered by the Registry (population 574 millions) 5.6 patients pmp commenced CAPD during 1982. Commencements reached 18.9 pmp in Switzerland, 17.4 pmp in the United Kingdom and 9.8 pmp in Italy. National programmes of CAPD fulfil different roles in the pattern of RRT and select different populations of patients. Therefore comparisons of the results achieved have not been made.

B-15 Engagement in Cognitively-Demanding Activities in Daily Life is Associated with Neurocognitive Test Performance and Perceived Cognitive Difficulties Among Adults With and Without HIV

Objective

Assessing daily activities is important for understanding how cognitive abilities affect everyday functioning. We evaluated a new measure capturing engagement in cognitively-demanding activities among people with and without HIV, and examined associations with neurocognitive test performance and perceived cognitive difficulties.

Method

Participants included 79 adults (59 HIV+, 20 HIV-) enrolled in studies at UCSD (mean age = 55.1; SD = 13.1). Domain-specific composite scaled scores measured neurocognitive functioning as continuous variables. Demographically-corrected global deficit scores determined neurocognitive impairment. Perceived cognitive difficulties were self-reported via the Everyday Cognition scale (ECog). The newly created, self-report Frequency and Difficulty of Activities Scale (FDAS) measured frequency of engagement in 27 cognitively-demanding activities [0 = Never to 10 = Once a day or more] in the last month. FDAS “total frequency score” sums all frequency ratings. Participants also rated difficulty performing each FDAS activity [0 = Not at all to 10 = Extremely]. FDAS “difficult-activity score” sums frequency ratings only for activities that participants identified as difficult for them (i.e., difficulty rating >75th percentile of sample).

Results

Higher FDAS total frequency scores correlated with better verbal fluency (r = 0.26, p = 0.019) and processing speed (r = 0.24, p = 0.030). Multiple regression revealed a significant interaction between cognitive impairment and frequency of engagement in difficult activities (b = 0.34, 95%CI = 0.18-0.50, p < 0.001), such that higher FDAS difficult-activity scores related to more perceived cognitive difficulties only among cognitively impaired participants.

Conclusion

This study explored use of a new measure of complex daily activities to aid neuropsychological interpretation. Results suggest that effects of neurocognitive impairment on perceived cognitive difficulties may only be apparent if individuals are attempting to perform challenging everyday tasks.

B-38 Gamified Mobile Cognitive Tests: Preliminary Feasibility and Acceptability in Persons with Bipolar Disorder

Objective

Current measurements of cognitive functioning are time-consuming and costly, often done as point-in-time assessments. We examined the feasibility and acceptability of six newly developed smartphone-based mobile cognitive tests (MCTs), completed in the real-world, among persons with bipolar disorder (BD) and healthy controls (HC).

Methods

Thirteen community-dwelling participants (seven BD and six HC), aged 18-65, completed in-person neurobehavioral assessments at baseline and our MCTs three times daily for the following 14 days. The MCTs measure cognition in the following domains: reaction time, executive functions, attention, processing speed, working memory, and learning and memory. Our protocol delivered 1-2 MCTs per session, and each test was only administered once daily. Timing of the MCTs was adjusted according to individual sleep/wake schedules.

Results

MCT adherence was, on average, high (82.38%). The two groups did not differ in terms of adherence (p = 0.45, 95% CI = -29.51, 13.96) or average completion time (5.21 mins, SD = 1.54 min per each assessment period; t(11) = 1.12, p = .29, 95% CI = -0.91, 2.81). There was no relationship between age and adherence (r = .296, p = .326). Acceptability was measured at follow-up via a Likert-scale rating from 0 = not at all to 4 = very much; mean likeability was high (M = 3.0, SD = 1.28). Most participants noted a high willingness to complete additional MCT testing in the future.

Conclusion

Our preliminary findings indicate mobile cognitive testing is feasible and accepted among bipolar disorder and comparison participants. The implications of using smartphone-based MCTs are far reaching, including increased visibility of cognitive changes over time as well as examining real-time temporal relationships between cognition and other lifestyle and environmental factors.

B-24 Objective and Subjective Sleep Measures are Associated with Neurocognition in Middle-Aged and Older Adults With and Without HIV

Objective

Poorer sleep quality is related to worse cognitive functioning in the general population and people living with HIV; however, many studies use self-report sleep questionnaires that rely on retrospective recall. This study aimed to examine the relationship between objective (wrist actigraphy) and subjective sleep quality with neurocognitive functioning.

Method

Eighty-five adults aged 50-74 years with and without HIV (HIV+ n = 53, HIV- n = 32) were recruited from the community and ongoing studies at UC San Diego. Participants completed comprehensive neuropsychological testing assessing global and domain-specific cognition. Participants wore actigraphy watches for 14 nights after neuropsychological testing to objectively assess sleep quality (i.e., total sleep time (TST), efficiency, wake after sleep onset, and sleep fragmentation). The Pittsburgh Sleep Quality Index assessed subjective sleep quality.

Results

After adjusting for demographic variables and use of sleep medications, there were no differences in any sleep quality measures by HIV status (p’s>0.05). In separate adjusted linear regression models, lower sleep efficiency (p = 0.02; 95% CI: -9.5, -1.1) and greater sleep fragmentation (p = 0.02; 95% CI: -0.82, -0.09) were associated with worse learning. Less TST was associated with worse working memory (p = 0.02; 95% CI: -9.2, -0.8). In contrast, worse subjective sleep quality was associated with worse executive function (p < 0.01; 95% CI: -1.18, -0.23) and working memory (p = 0.03; 95% CI: -1.22, -0.07).

Conclusion

Both objective and subjective sleep quality were associated with cognition in both persons with and without HIV; however, subjective and objective sleep quality were associated with different cognitive domains. Therefore, both objective and subjective sleep quality are important health behaviors to assess.

A-54 Greater Time Spent Watching TV is Related to Worse Real-Time Neurocognitive Performance in Older Adults With and Without HIV

Objective

There is a need to identify determinants of neurocognitive impairment among older persons living with HIV (PLHIV). Utilizing smartphone-based Ecological Momentary Assessment (EMA) and mobile cognitive testing, we examined the relationships between daily life activities and real-world neurocognitive performance among older PLHIV and HIV-uninfected adults.

Method

Ninety-one participants (58 PLHIV; Mage = 59.4, SD = 6.4), 70.3% male, 65.9% non-Hispanic white, completed four smartphone-based EMA surveys of daily activities and one mobile color-word interference test (mCWIT) per day for 14 days. Daily activities were grouped into five categories: activities of daily living (ADLs, IADLs), cognitively demanding activities, socially-engaging activities, physical activity (PA), and passive leisure activity (watching TV). Data was collapsed across the 14 days to examine between-person effects of the proportion of time reportedly spent on each activity on neurocognitive outcomes (the average correct responses and completion time for the mCWIT).

Results

No effect was found for engaging in activities by HIV status; however, PLHIV had significantly longer times on the mCWIT compared to persons without HIV (t = 2.49; 95% CI: 0.60, 5.37; p = 0.02). In a multivariable regression model accounting for HIV status, a greater proportion of time spent watching TV was associated with slower average mCWIT performance (beta = 9.41; 95% CI: 1.88,17.0; p = 0.01). There were no relationships between other domains of daily life activities and mCWIT performance.

Conclusion

Our findings provide evidence that more time spent watching TV is associated with slower mCWIT performance. Future work examining the time-lagged relationships between these variables is needed to understand whether watching TV decreases real-time neurocognitive performance.

C-25 Neurocognitive Correlates of Chronological and Subjective Age Differences in Persons Living with HIV compared to those without HIV

Objective

Investigate the discrepancy between subjective and chronologic age by HIV-serostatus, and the association of this discrepancy with subjective neurocognitive functioning (NCF) and objective NCF.

Methods

One hundred nineteen persons living with HIV (PWLH) and 98 HIV-uninfected (HIV-) adults (Mage = 50.9; SDage = 7.9) completed a comprehensive neurobehavioral battery. Subjective age was assessed using a single-item question (i.e., “how old do you feel?”). The difference between chronologic and subjective age resulted in subjective age discrepancy scores (SADS). Subjective NCF was measured using the Patient’s Assessment of Own Functioning Inventory; objective NCF was measured using global demographically-corrected T-scores. Linear regressions examined the association between subjective and objective NCF with SADS, covarying for significant PLWH and HIV- group differences (i.e., education, sex, ethnicity, and lifetime Major Depressive Disorder).

Results

PLWH reported lower SADS (indicating closer correspondence between chronologic and subjective age) than their HIV- counterparts, who reported feeling much younger (p = .05; 95% CI: -5.4, .001). Among PLWH, better subjective NCF was significantly related to greater SADS (p = .0002; 95% CI: -.48, -.16). Objective NCF was not associated with SADS among persons with and without HIV.

Conclusions

Adults without HIV reported feeling younger than their chronologic age, whereas PLWH felt significantly closer to their chronologic age. SADS were negatively associated with only subjective NCF, among only PLWH. This suggests perceived cognitive functioning has a greater impact on psychological well-being among this group. Future research is warranted to delineate the relationship between HIV, subjective neurocognition, and psychosocial factors related to daily functioning to improve successful aging outcomes among this vulnerable population.

Defects in the Exocyst-Cilia Machinery Cause Bicuspid Aortic Valve Disease and Aortic Stenosis

BACKGROUND

Bicuspid aortic valve (BAV) disease is a congenital defect that affects 0.5% to 1.2% of the population and is associated with comorbidities including ascending aortic dilation and calcific aortic valve stenosis. To date, although a few causal genes have been identified, the genetic basis for the vast majority of BAV cases remains unknown, likely pointing to complex genetic heterogeneity underlying this phenotype. Identifying genetic pathways versus individual gene variants may provide an avenue for uncovering additional BAV causes and consequent comorbidities.

METHODS

We performed genome-wide association Discovery and Replication Studies using cohorts of 2131 patients with BAV and 2728 control patients, respectively, which identified primary cilia genes as associated with the BAV phenotype. Genome-wide association study hits were prioritized based on P value and validated through in vivo loss of function and rescue experiments, 3-dimensional immunohistochemistry, histology, and morphometric analyses during aortic valve morphogenesis and in aged animals in multiple species. Consequences of these genetic perturbations on cilia-dependent pathways were analyzed by Western and immunohistochemistry analyses, and assessment of aortic valve and cardiac function were determined by echocardiography.

RESULTS

Genome-wide association study hits revealed an association between BAV and genetic variation in human primary cilia. The most associated single-nucleotide polymorphisms were identified in or near genes that are important in regulating ciliogenesis through the exocyst, a shuttling complex that chaperones cilia cargo to the membrane. Genetic dismantling of the exocyst resulted in impaired ciliogenesis, disrupted ciliogenic signaling and a spectrum of cardiac defects in zebrafish, and aortic valve defects including BAV, valvular stenosis, and valvular calcification in murine models.

CONCLUSIONS

These data support the exocyst as required for normal ciliogenesis during aortic valve morphogenesis and implicate disruption of ciliogenesis and its downstream pathways as contributory to BAV and associated comorbidities in humans.

NHS Health Check and healthy lifestyle in Leicester, England: analysis of a survey dataset

AIMS

A major component of the National Health Service (NHS) Health Check in England is to provide lifestyle advice to eligible participants. The aims of the study were to explore the variations (in terms of uptake) in the NHS Health Check in Leicester and to determine its association with a healthy lifestyle.

METHODS

This cross-sectional study used data from the Leicester Health and Wellbeing Survey (2015).

RESULTS

The odds of having an NHS Health Check were found to be higher in Black and minority ethnic groups and in people of other religions. The odds were lower in people without a religion, residing in the fourth index of multiple deprivation quintile and in ex-smokers. No associations were found between having an NHS Health Check and describing a healthy lifestyle, following a healthy lifestyle, thinking of making lifestyle changes in the next 6 months, cutting down on/stopping smoking among current smokers, or amount of alcohol current drinkers would like to drink.

CONCLUSIONS

In Leicester, a few variations in having an NHS Health Check were found among different socio-economic, demographic and behavioural groups. No association was found between the NHS Health Check and a healthy lifestyle. Thus, the improvement work should focus on reducing these variations in having the NHS Health Check and bringing its benefits on promoting a healthy lifestyle.

Role of lifestyle behaviours in the ethnic pattern of poor health outcomes in Leicester, England: analysis of a survey data set

OBJECTIVES

Mediation analyses were conducted to explore the contribution of lifestyle behaviours in the ethnic pattern of poor health outcomes in Leicester, England.

STUDY DESIGN

Cross-sectional study.

METHODS

The study used data on 1959 participants from the Leicester Health and Well-being Survey (2015). Lifestyle behaviours were physical activity, diet, smoking and alcohol drinking. Poor health outcomes were the presence of long-term illness and poor self-reported health.

RESULTS

Poor health outcomes were less common in Black and Minority Ethnic groups (BMEs) than Whites. Smoking was less common in BMEs than Whites. Poor health outcomes were more common in ex-smokers and current smokers than never smokers. Health outcomes were associated with smoking even after adjusting for ethnicity. The association of ethnicity and health outcomes reduced after adjusting for smoking, suggesting that the effect was mediated by smoking.

CONCLUSIONS

In Leicester, Whites had poorer health outcomes than BMEs, which were not mediated by physical activity, diet and alcohol drinking but were mediated by smoking.

Psychosocial student functioning in comprehensive dental clinic education: A qualitative study

INTRODUCTION

The aims were to describe first-year clinical dental students' psychosocial experiences in a known well-functioning comprehensive clinic teaching group (F+Grp) and a known dysfunctional group (Dys-Grp) and, thus, discover and describe phenomena related to psychosocial functioning of students. These groups were compared and contrasted regarding negative stress symptoms, perfectionism and coping with stress.

METHODS

Eight female dental students (mean 26 years old), four in each group, were interviewed after the first clinical year about learning and emotional experiences. The students also rated their perceived stress using a 0-10 scale, where 0 is no stress, and 10 is highest stress. Qualitative analyses involved searching for recurring themes and discovery of categories of clinical and social functioning. All 8 students were revisited as dentists after 8 years and filled out a 15-item survey as longitudinal validation of their first-year clinical experiences and to estimate group consensus and informant accuracy.

RESULTS

Both groups suffered from negative stress symptoms attributed to lack of time for clinical tasks, worries about work quality with confusion about their own expectations and worries about how others perceived them. Dys-Grp experienced higher negative stress and maladaptive perfectionism and described crying behaviours, withdrawal and unwillingness to cooperate with others. In contrast, students in F+Grp provided rich content about mutual cooperation related to social networking and positive support. The 8 subjects exhibited high internal consistency (α  =  .98) in their responses to the follow-up survey about their first year of clinic.

CONCLUSIONS

The comprehensive care teaching clinic environment with students working in groups appeared to provide a possibility for students to support each other for improved stress coping. Unfortunately, the opposite also occurred. Positive, supportive teacher supervision of student challenges related to perfectionism and stress is crucial and requires specific attention.

Assessing effects of behavioral intervention on treatment outcomes among patients initiating HIV care: Rationale and design of iENGAGE intervention trial

During the initial year of HIV diagnosis, while patients are often overwhelmed adjusting to this life changing diagnosis, they must develop self-care behaviors for attending regular medical care visits and antiretroviral therapy (ART) adherence to achieve and sustain viral suppression (VS). Maintaining "HIV adherence" and integrating it into one's daily life is required to sustain VS over time. The HIV care continuum or "treatment cascade," an epidemiological snapshot of the national epidemic in the United States (US), indicates that a minority of persons living with HIV (PLWH) have achieved VS. Little evidence exists regarding the effects of interventions focusing on PLWH newly initiating outpatient HIV care. An intervention that focuses on both retention in care and ART adherence skills delivered during the pivotal first year of HIV care is lacking. To address this, we developed a theory-based intervention evaluated in the Integrating Engagement and Adherence Goals upon Entry (iENGAGE) study, a National Institute of Allergy and Infectious Diseases (NIAID) funded randomized behavioral intervention trial. Here we present the study objectives, design and rationale, as well as the intervention components, targeting rapid and sustained VS through retention in HIV care and ART adherence during participants' first year of HIV care. The primary outcome of the study is 48-week VS (<200 c/mL). The secondary outcomes are retention in care, including HIV visit adherence and visit constancy, as well as ART adherence.

Search for the Exotic Meson X(5568) with the Collider Detector at Fermilab

A search for the exotic meson X(5568) decaying into the B_{s}^{0}π^{±} final state is performed using data corresponding to 9.6  fb^{-1} from pp[over ¯] collisions at sqrt[s]=1960  GeV recorded by the Collider Detector at Fermilab. No evidence for this state is found and an upper limit of 6.7% at the 95% confidence level is set on the fraction of B_{s}^{0} produced through the X(5568)→B_{s}^{0}π^{±} process.

Naloxone in the Treatment of Anorexia Nervosa: Effect on Weight Gain and Lipolysis

The effects of a constant intravenous infusion of naloxone in doses ranging from 3.2 to 6.4 mg/day were studied in a group of patients with anorexia nervosa. Patients showed a significantly greater weight gain during the infusion compared with the periods before and after naloxone. Plasma fJ-hydroxybutyrate and non-esterified fatty acid levels fell during the infusion. It is suggested that, in man, naloxone has an antilipolytic effect in vivo.

An evidence-based oral health promotion programme: Lessons from Leicester

OBJECTIVES

To provide an overview and draw lessons from the establishment of a local oral health promotion programme for preschool children in Leicester, England (2013-2017). The article provides information on the strategic approach taken in Leicester, one of the most ethnically diverse cities in England, and also one of the most deprived. Over a third of children aged 3 years, and half of those aged 5 years, have experience of obvious dental decay.

METHODS

A description of the evolution and development of the programme is provided along with commentary by the authors. This includes the origins, design and evaluation of the programme.

RESULTS

Progress so far has been promising. There has been a statistically significant 8% decrease in the proportion of 5-year-old children in Leicester with dental decay from 2011/2012 to 2014/2015. This will need to be sustained and further developed to deliver the 10% reduction required within the strategy.

CONCLUSIONS

The successful implementation of a local oral health improvement programme in Leicester has required leadership to coordinate a multiagency partnership approach to embedding effective concepts and realising opportunities collaboratively. However, longer term sustainability remains a concern.