Recruitment Strategies in the Integration of Mobile Health Into Sickle Cell Disease Care to Increase Hydroxyurea Utilization Study (meSH): Multicenter Survey Study

BACKGROUND

Hydroxyurea is an evidence-based disease-modifying therapy for sickle cell disease (SCD) but is underutilized. The Integration of Mobile Health into Sickle Cell Disease Care to Increase Hydroxyurea Utilization (meSH) multicenter study leveraged mHealth to deliver targeted interventions to patients and providers. SCD studies often underenroll; and recruitment strategies in the SCD population are not widely studied. Unanticipated events can negatively impact enrollment, making it important to study strategies that ensure adequate study accrual.

OBJECTIVE

The goal of this study was to evaluate enrollment barriers and the impact of modified recruitment strategies among patients and providers in the meSH study in response to a global emergency.

METHODS

Recruitment was anticipated to last 2 months for providers and 6 months for patients. The recruitment strategies used with patients and providers, new recruitment strategies, and recruitment rates were captured and compared. To document recruitment adaptations and their reasons, study staff responsible for recruitment completed an open-ended 9-item questionnaire eliciting challenges to recruitment and strategies used. Themes were extrapolated using thematic content analysis.

RESULTS

Total enrollment across the 7 sites included 89 providers and 293 patients. The study acceptance rate was 85.5% (382/447) for both patients and providers. The reasons patients declined participation were most frequently a lack of time and interest in research, while providers mostly declined because of self-perceived high levels of SCD expertise, believing they did not need the intervention. Initially, recruitment involved an in-person invitation to participate during clinic visits (patients), staff meetings (providers), or within the office (providers). We identified several important recruitment challenges, including (1) lack of interest in research, (2) lack of human resources, (3) unavailable physical space for recruitment activities, and (4) lack of documentation to verify eligibility. Adaptive strategies were crucial to alleviate enrollment disruptions due to the COVID-19 pandemic. These included remote approaching and consenting (eg, telehealth, email, and telephone) for patients and providers. Additionally, for patients, recruitment was enriched by simplification of enrollment procedures (eg, directly approaching patients without a referral from the provider) and a multitouch method (ie, warm introductions with flyers, texts, and patient portal messages). We found that patient recruitment rates were similar between in-person and adapted (virtual with multitouch) approaches (167/200, 83.5% and 126/143, 88.1%, respectively; P=.23). However, for providers, recruitment was significantly higher for in-person vs remote recruitment (48/50, 96% and 41/54, 76%, respectively, P<.001).

CONCLUSIONS

We found that timely adaptation in recruitment strategies secured high recruitment rates using an assortment of enriched remote recruitment strategies. Flexibility in approach and reducing the burden of enrollment procedures for participants aided enrollment. It is important to continue identifying effective recruitment strategies in studies involving patients with SCD and their providers and the impact and navigation of recruitment challenges.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT03380351; https://clinicaltrials.gov/study/NCT03380351.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/16319.

Weight Loss in Short-Term Interventions for Physical Activity and Nutrition Among Adults With Overweight or Obesity: A Systematic Review and Meta-Analysis

Introduction

Reaching, enrolling, and retaining participants in lengthy lifestyle change interventions for weight loss is a major challenge. The objective of our meta-analysis was to investigate whether lifestyle interventions addressing nutrition and physical activity lasting 6 months or less are effective for weight loss.

Methods

We searched for peer-reviewed studies on lifestyle change interventions of 6 months or less published from 2012 through 2023. Studies were screened based on inclusion criteria, including randomized controlled trials (RCTs) for adults with overweight or obesity. We used a random-effects model to pool the mean difference in weight loss between intervention and control groups. We also performed subgroup analyses by intervention length and control type.

Results

Fourteen RCTs were identified and included in our review. Half had interventions lasting less than 13 weeks, and half lasted from 13 to 26 weeks. Seven were delivered remotely, 4 were delivered in person, and 3 used combined methods. The pooled mean difference in weight change was -2.59 kg (95% CI, -3.47 to -1.72). The pooled mean difference measured at the end of the intervention was -2.70 kg (95% CI, -3.69 to -1.71) among interventions lasting less than 13 weeks and -2.40 kg (95% CI, -4.44 to -0.37) among interventions of 13 to 26 weeks.

Conclusion

Short-term multicomponent interventions involving physical activity and nutrition can achieve weight loss for adults with overweight or obesity. Offering short-term interventions as alternatives to long-term ones may reach people who otherwise would be unwilling or unable to enroll in or complete longer programs.

Integrating the Consolidated Framework for Implementation Research (CFIR) into a Culturally Responsive Evaluation (CRE) Approach to Conduct Mixed-Method Evaluations of Diabetes Prevention and Management Programs Reaching Underresourced Populations and Communities

Diabetes is a significant population health threat. Evidence-based interventions, such as the Centers for Disease Control and Prevention's National Diabetes Prevention Program and diabetes self-management education and support programs, can help prevent, delay, or manage the disease. However, participation is suboptimal, especially among populations who are at an increased risk of developing diabetes. Evaluations of programs reaching populations who are medically underserved or people with lower incomes can help elucidate how best to tailor evidence-based interventions, but it is also important for evaluations to account for cultural and contextual factors. Culturally responsive evaluation (CRE) is a framework for centering an evaluation in the culture of the programs being evaluated. We integrated CRE with implementation and outcome constructs from the Adapted Consolidated Framework for Implementation Research (CFIR) to ensure that the evaluation produced useful evidence for putting evidence-based diabetes interventions to use in real-world settings, reaching populations who are at an increased risk of developing diabetes. The paper provides an overview of how we integrated CRE and CFIR approaches to conduct mixed-methods evaluations of evidence-based diabetes interventions.

Citizen science in hydrological monitoring and ecosystem services management: State of the art and future prospects

Hydrological monitoring is essential to guide evidence-based decision making necessary for sustainable water resource management and governance. Limited hydrometric datasets and the pressure on long-term hydrological monitoring networks make it paramount to explore alternative methods for data collection. This is particularly the case for low-income countries, where data scarcity is more pronounced, and where conventional monitoring methods are expensive and logistically challenging. Citizen science in hydrological research has recently gained popularity and crowdsourced monitoring is a promising cost-effective approach for data collection. Citizen science also has the potential to enhance knowledge co-creation and science-based evidence that underpins the governance and management of water resources. This paper provides a comprehensive review on citizen science and crowdsourced data collection within the context of hydrology, based on a synthesis of 71 articles from 2001 to 2018. Application of citizen science in hydrology is increasing in number and breadth, generating a plethora of scientific data. Citizen science approaches differ in scale, scope and degree of citizen involvement. Most of the programs are found in North America and Europe. Participation mostly comprises a contributory citizen science model, which engages citizens in data collection. In order to leverage the full potential of citizen science in knowledge co-generation, future citizen science projects in hydrology could benefit from more co-created types of projects that establish strong ties between research and public engagement, thereby enhancing the long-term sustainability of monitoring networks.

A qualitative framework-based evaluation of radiology clinical decision support initiatives: eliciting key factors to physician adoption in implementation

Objectives

To illustrate key contextual factors that may have effects on clinical decision support (CDS) adoption and, ultimately, success.

Materials and Methods

We conducted a qualitative evaluation of 2 similar radiology CDS innovations for near-term endpoints affecting adoption and present the findings using an evaluation framework. We identified key contextual factors between these 2 innovations and determined important adoption differences between them.

Results

Degree of electronic health record integration, approach to education and training, key drivers of adoption, and tailoring of the CDS to the clinical context were handled differently between the 2 innovations, contributing to variation in their relative degrees of adoption and use. Attention to these factors had impacts on both near and later-term measures of success (eg, patient outcomes).

Discussion

CDS adoption is a well-studied early-term measure of CDS success that directly impacts outcomes. Adoption requires attention throughout the design phases of an intervention especially to key factors directly affecting it, including how implementation across multiple sites and systems complicates adoption, which prior experience with CDS matters, and that practice guidelines invariably require tailoring to the clinical context.

Conclusion

With better planning for the capture of early-term measures of successful CDS implementation, especially adoption, critical adjustments may be made to ensure that the CDS is effectively implemented to be successful.

Citizen science pioneers in Kenya - A crowdsourced approach for hydrological monitoring

Although water is involved in many ecosystem services, the absence of monitoring data restricts the development of effective water management strategies especially in remote regions. Traditional monitoring networks can be expensive, with unaffordable costs in many low-income countries. Involving citizens in monitoring through crowdsourcing has the potential to reduce these costs but remains uncommon in hydrology. This study evaluates the quality and quantity of data generated by citizens in a remote Kenyan basin and assesses whether crowdsourcing is a suitable method to overcome data scarcity. We installed thirteen water level gauges equipped with signboards explaining the monitoring process to passers-by. Results were sent via a text-message-based data collection framework that included an immediate feedback to citizens. A public web interface was used to visualize the data. Within the first year, 124 citizens reported 1175 valid measurements. We identified thirteen citizens as active observers providing more than ten measurements, whereas 57% only sent one record. A comparison between the crowdsourced water level data and an automatic gauging station revealed high data quality. The results of this study indicate that citizens can provide water level data of sufficient quality and with high temporal resolution.

Strategies for Successful Survivorship Care Plan Implementation: Results From a Qualitative Study

INTRODUCTION

Care for US cancer survivors is often fragmented, contributing to poor health outcomes. Care and outcomes may improve when survivors and follow-up care providers receive survivorship care plans (SCPs), written documents containing information regarding cancer diagnosis, treatment, surveillance plans, and health promotion. However, implementing SCPs is challenging. As such, we sought to identify strategies for successfully implementing SCPs.

METHODS

We measured SCP implementation using performance data from cancer programs participating in the American Society of Clinical Oncology Quality Oncology Practice Initiative, an oncologist-led quality assessment and improvement program. We used semistructured interviews with cancer program employees (eg, physicians) to identify strategies for successfully implementing SCPs by comparing approaches in cancer programs that, according to Quality Oncology Practice Initiative performance indicators, developed and delivered SCPs to a relatively small proportion of eligible survivors and their follow-up care providers (ie, low performers; n = 6 participants in five programs) with approaches among programs with better performance (ie, moderate performers; n = 15 participants in nine programs).

RESULTS

Ten of 14 cancer programs developed SCPs for ≥ 50% of eligible survivors; two of 14 delivered SCPs to any survivors; and eight of 14 delivered SCPs to ≥ 25% of follow-up care providers. We found that moderate performers proactively addressed SCP requirements, leveraged requirements to improve survivorship care, set internal targets, automated implementation, had active leaders and champions, and tasked appropriate employees with SCP implementation.

CONCLUSION

SCP implementation remains challenging. We identified strategies for successfully implementing SCPs. Future research should examine how cancer programs have achieved these strategies; findings could contribute to an understanding of the changes needed to implement comprehensive survivorship care.

Determining the predictors of innovation implementation in healthcare: a quantitative analysis of implementation effectiveness

BACKGROUND

The failure rates for implementing complex innovations in healthcare organizations are high. Estimates range from 30% to 90% depending on the scope of the organizational change involved, the definition of failure, and the criteria to judge it. The innovation implementation framework offers a promising approach to examine the organizational factors that determine effective implementation. To date, the utility of this framework in a healthcare setting has been limited to qualitative studies and/or group level analyses. Therefore, the goal of this study was to quantitatively examine this framework among individual participants in the National Cancer Institute's Community Clinical Oncology Program using structural equation modeling.

METHODS

We examined the innovation implementation framework using structural equation modeling (SEM) among 481 physician participants in the National Cancer Institute's Community Clinical Oncology Program (CCOP). The data sources included the CCOP Annual Progress Reports, surveys of CCOP physician participants and administrators, and the American Medical Association Physician Masterfile.

RESULTS

Overall the final model fit well. Our results demonstrated that not only did perceptions of implementation climate have a statistically significant direct effect on implementation effectiveness, but physicians' perceptions of implementation climate also mediated the relationship between organizational implementation policies and practices (IPP) and enrollment (p <0.05). In addition, physician factors such as CCOP PI status, age, radiological oncologists, and non-oncologist specialists significantly influenced enrollment as well as CCOP organizational size and structure, which had indirect effects on implementation effectiveness through IPP and implementation climate.

CONCLUSIONS

Overall, our results quantitatively confirmed the main relationship postulated in the innovation implementation framework between IPP, implementation climate, and implementation effectiveness among individual physicians. This finding is important, as although the model has been discussed within healthcare organizations before, the studies have been predominately qualitative in nature and/or at the organizational level. In addition, our findings have practical applications. Managers looking to increase implementation effectiveness of an innovation should focus on creating an environment that physicians perceive as encouraging implementation. In addition, managers should consider instituting specific organizational IPP aimed at increasing positive perceptions of implementation climate. For example, IPP should include specific expectations, support, and rewards for innovation use.

Organizational and physician factors associated with patient enrollment in cancer clinical trials

BACKGROUND

Our purpose was to identify physicians' individual characteristics, attitudes, and organizational contextual factors associated with higher enrollment of patients in cancer clinical trials among physician participants in the National Cancer Institute's Community Clinical Oncology Program (CCOP). We hypothesized that physicians' individual characteristics, such as age, medical specialty, tenure, CCOP organizational factors (i.e. policies and procedures to encourage enrollment), and attitudes toward participating in CCOP would directly determine enrollment. We also hypothesized that physicians' characteristics and CCOP organizational factors would influence physicians' attitudes toward participating in CCOP, which in turn would predict enrollment.

METHODS

We evaluated enrollment in National Cancer Institute-sponsored cancer clinical trials in 2011 among 481 physician participants using Structural Equation Modeling. The data sources include CCOP Annual Progress Reports, two surveys of CCOP administrators and physician participants, and the American Medical Association Masterfile.

RESULTS

Physicians with more positive attitudes toward participating in CCOP enrolled more patients than physicians with less positive attitudes. In addition, physicians who practiced in CCOPs that had more supportive policies and practices in place to encourage enrollment (i.e. offered trainings, provided support to screen and enroll patients, gave incentives to enroll patients, instituted minimum accrual expectations) also significantly enrolled more patients. Physician status as CCOP Principal Investigator had a positive direct effect on enrollment, while physician age and non-oncology medical specialty had negative direct effects on enrollment. Neither physicians' characteristics nor CCOP organizational factors indirectly influenced enrollment through an effect on physician attitudes.

CONCLUSION

We examined whether individual physicians' characteristics and attitudes, as well as CCOP organizational factors, influenced patient enrollment in cancer clinical trials among CCOP physicians. Physician attitudes and CCOP organizational factors had positive direct effects, but not indirect effects, on physician enrollment of patients. Our results could be used to develop physician-directed strategies aimed at increasing involvement in clinical research. For example, administrators may want to ensure physicians have access to support staff to help screen and enroll patients or institute minimum accrual expectations. Our results also highlight the importance of recruiting physicians for volunteer clinical research programs whose attitudes and values align with programmatic goals. Given that physician involvement is a key determinant of patient enrollment in clinical trials, these interventions could expand the overall number of patients involved in cancer research. These strategies will be increasingly important as the CCOP network continues to evolve.

Assessing the feasibility of a virtual tumor board program: a case study

Multidisciplinary tumor boards involve various providers (e.g., oncology physicians, nurses) in patient care. Although many community hospitals have local tumor boards that review all types of cases, numerous providers, particularly in rural areas and smaller institutions, still lack access to tumor boards specializing in a particular type of cancer (e.g., hematologic). Videoconferencing technology can connect providers across geographic locations and institutions; however, virtual tumor board (VTB) programs using this technology are uncommon. In this study, we evaluated the feasibility of a new VTB program at the University of North Carolina (UNC) Lineberger Comprehensive Cancer Center, which connects community-based clinicians to UNC tumor boards representing different cancer types. Methods included observations, interviews, and surveys. Our findings suggest that participants were generally satisfied with the VTB. Cases presented to the VTB were appropriate, sufficient information was available for discussion, and technology problems were uncommon. UNC clinicians viewed the VTB as a service to patients and colleagues and an opportunity for clinical trial recruitment. Community-based clinicians presenting at VTBs valued the discussion, even if it simply confirmed their original treatment plan or did not yield consensus recommendations. Barriers to participation for community-based clinicians included timing of the VTB and lack of reimbursement. To maximize benefits of the VTB, these barriers should be addressed, scheduling and preparation processes optimized, and appropriate measures for evaluating impact identified.

Context matters: measuring implementation climate among individuals and groups

BACKGROUND

It has been noted that implementation climate is positively associated with implementation effectiveness. However, issues surrounding the measurement of implementation climate, or the extent to which organizational members perceive that innovation use is expected, supported and rewarded by their organization remain. Specifically, it is unclear whether implementation climate can be measured as a global construct, whether individual or group-referenced items should be used, and whether implementation climate can be assessed at the group or organizational level.

METHODS

This research includes two cross-sectional studies with data collected via surveys at the individual level. The first study assessed the implementation climate perceptions of physicians participating in the National Cancer Institute's (NCI) Community Clinical Oncology Program (CCOP), and the second study assessed the perceptions of children's behavioral health clinicians implementing a treatment innovation. To address if implementation climate is a global construct, we used confirmatory factor analysis. To address how implementation climate should be measured and at what level, we followed a five-step framework outlined by van Mierlo and colleagues. This framework includes exploratory factor analysis and correlations to assess differences between individual and group-referenced items and intraclass correlations, interrater agreements, and exploratory factor analysis to determine if implementation climate can be assessed at the organizational level.

RESULTS

The confirmatory factor analysis demonstrated that implementation climate is a global construct consisting of items related to expectations, support and rewards. There are mixed results, however, as to whether implementation climate should be measured using individual or group-referenced items. In our first study, where physicians were geographically dispersed and practice independently, there were no differences based on the type of items used, and implementation climate was an individual level construct. However, in the second study, in which clinicians practice in a central location and interact more frequently, group-referenced items may be appropriate. In addition, implementation climate could be considered an organizational level construct.

CONCLUSIONS

The results are context-specific. Researchers should carefully consider the study setting when measuring implementation climate. In addition, more opportunities are needed to validate this measure and understand how well it predicts and explains implementation effectiveness.

Organizational readiness for implementing change: a psychometric assessment of a new measure

Background

Organizational readiness for change in healthcare settings is an important factor in successful implementation of new policies, programs, and practices. However, research on the topic is hindered by the absence of a brief, reliable, and valid measure. Until such a measure is developed, we cannot advance scientific knowledge about readiness or provide evidence-based guidance to organizational leaders about how to increase readiness. This article presents results of a psychometric assessment of a new measure called Organizational Readiness for Implementing Change (ORIC), which we developed based on Weiner’s theory of organizational readiness for change.

Methods

We conducted four studies to assess the psychometric properties of ORIC. In study one, we assessed the content adequacy of the new measure using quantitative methods. In study two, we examined the measure’s factor structure and reliability in a laboratory simulation. In study three, we assessed the reliability and validity of an organization-level measure of readiness based on aggregated individual-level data from study two. In study four, we conducted a small field study utilizing the same analytic methods as in study three.

Results

Content adequacy assessment indicated that the items developed to measure change commitment and change efficacy reflected the theoretical content of these two facets of organizational readiness and distinguished the facets from hypothesized determinants of readiness. Exploratory and confirmatory factor analysis in the lab and field studies revealed two correlated factors, as expected, with good model fit and high item loadings. Reliability analysis in the lab and field studies showed high inter-item consistency for the resulting individual-level scales for change commitment and change efficacy. Inter-rater reliability and inter-rater agreement statistics supported the aggregation of individual level readiness perceptions to the organizational level of analysis.

Conclusions

This article provides evidence in support of the ORIC measure. We believe this measure will enable testing of theories about determinants and consequences of organizational readiness and, ultimately, assist healthcare leaders to reduce the number of health organization change efforts that do not achieve desired benefits. Although ORIC shows promise, further assessment is needed to test for convergent, discriminant, and predictive validity.

Achieving high cancer control trial enrollment in the community setting: an analysis of the Community Clinical Oncology Program

Determining the factors that lead to successful enrollment of patients in cancer control clinical trials is essential as cancer patients are often burdened with side effects such as pain, nausea, and fatigue. One promising intervention for increasing enrollment in cancer control trials is the National Cancer Institute's Community Clinical Oncology Program (CCOP). In this article, we examined CCOP staffing, policies, and procedures associated with enrollment in control trials. Data were obtained from three sources: the online CCOP, MB-CCOP, and Research Base Management System, CCOP Annual Progress Reports, and a survey of CCOP Administrators conducted in 2011. We analyzed cancer control trial accrual in 2011 among 46 CCOPs using multivariate regression. Three factors were significant predictors of accrual. First, having a team of staff dedicated to enrolling patients in control and prevention trials, compared to having no dedicated staff, was associated on average with an additional 30 patients enrolled in control trials (p<0.05). Second, CCOPs that recognized physicians for enrolling a large number of patients compared to CCOPs that did not recognize high enrolling physicians enrolled on average an additional 25 patients in control trials (p<0.05). Lastly, the number of cancer control trials available was also associated with enrollment (β=5.50, p<0.00). Our results indicate that CCOPs looking to increase enrollment in control trials should consider dedicating a team of staff to enroll patients in these types of trials. In addition, CCOPs or other volunteer research systems looking to increase physician participation should consider recognizing high enrolling physicians.

Organizational designs for achieving high treatment trial enrollment: a fuzzy-set analysis of the community clinical oncology program

PURPOSE

To examine the organizational design features that were consistently associated in 2010 with high levels of patient enrollment onto National Cancer Institute (NCI) cancer treatment trials among the oncology practices and hospitals participating in the NCI Community Clinical Oncology Program (CCOP).

METHODS

Fuzzy-set qualitative comparative analysis was used to identify the recipes (ie, combinations of organizational design features) that CCOPs used to achieve high levels of patient enrollment onto NCI treatment trials in 2010. Four organizational design features were examined: number of open treatment trials with at least one patient enrolled, number of newly diagnosed patients with cancer, number of CCOP-affiliated physicians, and number of CCOP-affiliated hospitals or practices where patient enrollment could occur. Data were obtained from NCI data systems and CCOP grant progress reports.

RESULTS

Two recipes were consistently associated with high levels of patient enrollment onto NCI treatment trials in 2010: having many open treatment trials and many new patients with cancer, and having many open treatment trials and many affiliated hospitals or practices. Together, these recipes accounted for nearly two thirds of CCOP membership in the high-performance set in 2010.

CONCLUSION

No single organizational design feature, by itself, was consistently associated with high levels of patient enrollment onto NCI treatment trials in 2010. Having a large menu of active treatment trials may be necessary to achieve high-patient enrollment performance, but this is not sufficient unless combined with either large patient volume or many participating sites.

Accuracy and reliability of self-reported weight and height in the Sister Study

OBJECTIVE

To assess the accuracy and reliability of self-reported weight and height and identify the factors associated with reporting accuracy.

DESIGN

Analysis of self-reported and measured weight and height from participants in the Sister Study (2003-2009), a nationwide cohort of 50 884 women aged 35-74 years in the USA with a sister with breast cancer.

SETTING

Weight and height were reported via computer-assisted telephone interview (CATI) and self-administered questionnaires, and measured by examiners.

SUBJECTS

Early enrolees in the Sister Study. There were 18 639 women available for the accuracy analyses and 13 316 for the reliability analyses.

RESULTS

Using weighted kappa statistics, comparisons were made between CATI responses and examiner measures to assess accuracy and CATI and questionnaire responses to assess reliability. Polytomous logistic regression evaluated factors associated with over- or under-reporting. Compared with measured values, agreement was 96 % for reported height (±1 inch (±2·5 cm); weighted κ = 0·84) and 67 % for weight (±3 lb (±1·36 kg); weighted κ = 0·92). Obese women (BMI ≥ 30 kg/m2) were more likely than normal-weight women to under-report weight by ≥5 % and underweight women (BMI < 18·5 kg/m2) were more likely to over-report. Among normal-weight and overweight women (18·5 kg/m2 ≤ BMI < 30 kg/m2), weight cycling and lifetime weight difference ≥50 lb (≥22·68 kg) were associated with over-reporting.

CONCLUSIONS

US women in the Sister Study were reasonably reliable and accurate in reporting weight and height. Women with normal-range BMI reported most accurately. Overweight and obese women and those with weight fluctuations were less accurate, but even among obese women, few under-reported their weight by >10 %.

Autophagy is essential to suppress cell stress and to allow BCR-Abl-mediated leukemogenesis

Hematopoietic cells normally require cell extrinsic signals to maintain metabolism and survival. In contrast, cancer cells can express constitutively active oncogenic kinases such as BCR-Abl that promote these processes independent of extrinsic growth factors. When cells receive insufficient growth signals or when oncogenic kinases are inhibited, glucose metabolism decreases and the self-digestive process of autophagy is elevated to degrade bulk cytoplasm and organelles. While autophagy has been proposed to provide a cell-intrinsic nutrient supply for mitochondrial oxidative metabolism and to maintain cellular homeostasis through degradation of damaged organelles or protein aggregates, its acute role in growth factor deprivation or inhibition of oncogenic kinases remains poorly understood. We therefore developed a growth factor-dependent hematopoietic cell culture model in which autophagy can be acutely disrupted through conditional Cre-mediated excision of the autophagy-essential gene Atg3. Treated cells rapidly lost their ability to perform autophagy and underwent cell cycle arrest and apoptosis. While Atg3 was essential for optimal upregulation of mitochondrial oxidative pathways in growth factor withdrawal, this metabolic contribution of autophagy did not appear critical for cell survival, as provision of exogenous pyruvate or lipids could not completely rescue Atg3-deficiency. Instead, autophagy suppressed a stress response that otherwise led to p53 phosphorylation and upregulation of p21 and the pro-apoptotic Bcl-2 family protein Puma. Importantly, BCR-Abl-expressing cells had low basal levels of autophagy but were highly dependent on this process, and rapidly underwent apoptosis upon disruption of autophagy through Atg3 deletion or treatment with chemical autophagy inhibitors. This dependence on autophagy extended in vivo, as Atg3 deletion also prevented BCR-Abl-mediated leukemogenesis in a cell transfer model. Together these data demonstrate a critical role for autophagy to mitigate cell stress, and that cells expressing the oncogenic kinase BCR-Abl appear particularly dependent on autophagy for cell survival and leukemogenesis.

A survey of the prevalence of Giardia in dogs presented to Canadian veterinary practices

Fecal samples (1216) were collected from dogs presented to 15 veterinary practices across Canada and tested for Giardia by ELISA for group-specific antigen. If positive, the presence of Giardia was confirmed by microscopy. Eighty-eight submissions tested positive by ELISA and microscopy. The overall prevalence rate of Giardia was 7.2%.

Emergency care in patients wearing body casts

OBJECTIVE

To describe a body cast modification that allows rapid chest exposure for cardiopulmonary resuscitation and alert the medical community to the 3% to 5% incidence of cardiopulmonary arrest in the hospital while wearing such a cast. DESIGN. Single trial timed cast cutting, multiple trial cast shell loading, and clinical observations of perforated casts for cracking or breakage.

SETTING

University hospital castroom, mechanical engineering laboratory.

INTERVENTION

Body casts mounted on a life-sized torso mold were perforated at 2-inch (50 mm), 1-inch (25 mm), or 1/2 inch (12 mm) intervals around the chest with a 12-mm-diameter vibrating drill. Using a cast saw, the chest piece of each body cast was removed and the time recorded. Engineering studies were performed on two cast shells with and without 12-mm-wide holes up to 1/2" (12 mm) apart, loading the fiberglass to the point of failure and recording the data. Body casts with 1" (25 mm)-interval holes worn by 40 patients were examined after 12 weeks for evidence of failure.

MAIN OUTCOME MEASURES

Chest piece removal times of body cast shells with and without holes were compared. Loading data of cast shells were compared to determine if holes as close as 1/2" (12 mm) significantly weakened the cast. Forty casts, perforated at 1-inch (25 mm) intervals, were observed for failure after 12 weeks of wear.

RESULTS

Chest exposure time of a mold encased in a fiberglass cast was reduced from 1 minute to 15 seconds; plaster cast removal was reduced from 3 minutes to 1 minute. Engineering studies of perforated casts showed no significant decrease in strength. Casts with and without holes could support chest forces of up to 330 pounds. No failure was observed in casts with perforations 1 inch (25 mm) apart worn for 12 weeks.

CONCLUSION

Perforated body casts reduced removal time to 15 seconds without weakening of the cast and provide lifesaving time to perform effective CPR.

Intrauterine onset of a mononeuropathy: peroneal neuropathy in a newborn with electromyographic findings at age one day compatible with prenatal onset

Mononeuropathies are unusual at birth, and electromyographic (EMG) definition the first day of life has not been reported previously. Although neonatal mononeuropathies may be related to obstetric complications, prenatal mechanisms also merit consideration. We report an infant, born with a peroneal neuropathy, whose EMG was performed 18 h after birth. An isolated peroneal nerve lesion with lack of compound muscle action potential and the presence of fibrillation potentials, confined to the tibialis anterior muscle, suggested a primary intrauterine mechanism for this mononeuropathy. Because of an infant's small size, the temporal profile used in adults for appearance of EMG signs of wallerian degeneration may not apply. Inaccurate conclusions may result if the EMG standards for timing adult nerve injury are applied to newborns. To our knowledge, previous published cases of neonatal mononeuropathies have not included babies whose first EMG was performed before age 4 days. Therefore, an EMG study shortly after birth needed to be accomplished if strong support for the hypothesis of a prenatal onset were to be generated. Our findings are compatible with an intrauterine onset of this baby's peroneal neuropathy.

Future ambulation prognosis as predicted by somatosensory evoked potentials in motor complete and incomplete quadriplegia

OBJECTIVE

The purpose of this prospective study was to determine the efficacy of tibial somatosensory evoked potentials (SEPs) in predicting ambulation in tetraplegic individuals.

DESIGN

This was a prospective study of a cohort of cervical spinal cord-injured patients who had SEPs recorded within 72 hours to 2 weeks post-SCI and whose ambulation outcome was followed up to 2 years post-SCI.

SETTING

Regional Spinal Cord Injury (SCI) Center.

PATIENTS

All male and female subjects admitted to the center from 1988 to 1991 between the ages of 15 and 60 years who demonstrated C4 through T1 complete and incomplete acute SCIs were asked to participate in this study.

MEASUREMENTS

The tibial nerve cortical SEPs were graded as either present or absent. The waveforms were also graded as less than 0.5 microV or > or = 0.5 microV. Quadriceps strength plus touch and pin sensation were tested within 72 hours to 2 weeks post-SCI. Ambulation was rated as absent, exercise, household, or community. The ambulatory and clinical status were assessed monthly for 3 months, and then at 6, 12, 18, and 24 months post-SCI. Statistical analysis using the two-tailed Fisher's exact test was performed relating the initial clinical and SEP data to ambulation outcome up to 24 months post-SCI.

RESULTS

All 13 subjects with a right and/or left quadriceps manual muscle test (MMT) greater than 0/5 became ambulatory. Of the 9 subjects with an initial bilateral quadriceps MMT = 0/5, only 1 recovered enough lower limb function to ambulate (p = .0001). One of the 7 subjects with absent touch sensation in the lower limbs became ambulatory, whereas 14 of the 15 subjects with touch sensation present became ambulatory (p = .002). All 7 subjects with absent pin sensation in the lower limbs were nonambulatory, and 14 of 15 subjects with pin sensation present became ambulatory (p < .0001). Of the 9 subjects with bilaterally absent cortical SEP waveforms, 2 became ambulatory. Twelve of the 13 subjects with a cortical SEP wave present became ambulatory (p = .0015). Of the 10 subjects with a cortical SEP wave amplitude less than 0.5 microV, only two became ambulatory, whereas all 12 subjects with an amplitude > or = 0.5 microV became ambulatory (p = .00014). In no subject did the SEP predict future ambulation where the clinical examination did not also predict recovery of ambulation.

CONCLUSION

Both the early postinjury clinical evaluation and the SEP predicted ambulation outcome to a significant degree, but the SEP offered no additional prognostic accuracy over that provided by the clinical examination.

Pin sensation as a predictor of extensor carpi radialis recovery in spinal cord injury

The purpose of this prospective study was to determine if initial preservation of C5 pin sensation could predict extensor carpi radialis (ECR) motor recovery in the zone of partial preservation after spinal cord injury (SCI). The study compared initial C5 pin sensation and initial ECR strength as predictors of ECR motor recovery after C4 and C5 SCI. The initial motor and sensory evaluation was done less than seven days after injury. Motor power was graded from absent (0/5) to normal strength (5/5). Pin sensation was graded as absent (0/2) decreased (1/2) or normal (2/2). The manual muscle test was performed weekly to four weeks and than at three, six, and 12 months after injury. An ECR muscle grade of > or = 3/5 was defined as recovery. C5 pin sensation at the lateral antecubital fossa significantly correlated with ECR recovery to > or = 3/5 (p < 0.001). Only two of nine subjects with absent C5 pin sensation recovered ECR to > or = 3/5, whereas 14 of 15 subjects with 1/2 or 2/2 C5 pin sensation had ECR motor recovery to > or = 3/5. All ten subjects with 1/5 or 2/5 initial ECR strength had ECR motor recovery. Five of six subjects with 0/5 initial ECR strength and subsequent ECR recovery to > or = 3/5 were found to have C5 pin preservation. In conclusion the presence of 1/5 to 2/5 initial ECR strength or 1/2 or 2/2 C5 pin sensation were highly significant predictors of ECR motor recovery to > or = 3/5 in C4 and C5 motor complete quadriplegic subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Extensor carpi radialis recovery predicted by qualitative SEP and clinical examination in quadriplegia

This prospective study examined the efficacy of the qualitative somatosensory evoked potential (SEP) and the initial clinical neurologic evaluation to predict motor power recovery of the extensor carpi radialis muscle (ECR). Twenty three C5-6 Frankel A-D spinal cord injured (SCI) subjects had SEPs of the median nerve (MN) and superficial radial nerve (SRN) performed within 72 hours to one week post injury. The MN and SRN cortical SEPs were qualitatively graded as either present or absent. Fifteen subjects whose initial ECR muscle strength was less than or equal to 3/5 and eight subjects whose muscle strength was greater than 3/5 were followed up to 12 to 18 months post injury for improvement in ECR muscle strength. The subject's ECR strength was evaluated by manual muscle testing (MMT) at 72 hours, weekly for three weeks, monthly for three months, and then at six, 12, and 18 months. The pin sensation at the C-5 dermatome was also tested at the above intervals and graded as either present or absent. A one tail Fisher Exact test compared the presence or absence of the MN and SRN SEPs to the recovery of the ECR to 3/5. The same one tail test also compared the presence or absence of the 72 hour C-5 pin sensation and the 72 hour MMT to the ECR recovery. Among the 15 subjects with an initial MMT of less than or equal to 3/5, ten subjects had successful ECR recovery (greater than 3/5); 5 did not. The C-5 pin sensation correctly predicted ECR recovery in all subjects studied (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Cutaneous Hodgkin's disease in a patient with human immunodeficiency virus infection

A 22-year-old man with human immunodeficiency virus infection had skin nodules of the chest wall. When a biopsy was performed on these nodules, Hodgkin's disease was discovered. The patient was subsequently found to have widespread disease involving the lymph nodes and liver. Skin involvement with Hodgkin's disease is rare. In this report, we review previous descriptions of skin involvement appearing in the literature.

Medically reversible quadriparesis in tophaceous gout

This case report presents a successful nonoperative outcome of a type II odontoid fracture secondary to severe tophaceous gout. The patient presented with spastic quadriparesis and tophaceous involvement of the odontoid process with fracture and C1-C2 instability. He refused surgery. However, his odontoid process stabilized with the used of a collar, and he regained almost normal strength plus independence in self-care and ambulation, demonstrating that an unstable type II odontoid fracture secondary to tophaceous gout can stabilize with conservative management.

Rehabilitation of the person with arthritis of the ankle and foot

When combined with skillful pharmacologic management, applying the full stock of biomechanical principles available to the rheumatoid foot and ankle is very effective in avoiding the need for surgery and slowing or preventing deformity. The general principles of arthritis rehabilitation also help restore function. When good medical management, joint protection, exercise, and energy conservation techniques are combined with psychosocial vocational therapy as needed, the crippling loss of function so often seen in the past can be largely avoided.

Cytochemical and competitive protein binding assays for estrogen receptor in breast disease. A comparative study of 62 cases

Estrogen receptor content of breast lesions was estimated using a fluorescent cytochemical technique and a competitive protein binding assay. Of 48 cancers examined, an equal proportion contained significant quantities of receptor by either method (62.5%). The concordance between methods for individual patients was also 62.5%. A greater proportion (26%) of patients younger than 45 years of age had receptor-positive cancers using the cytochemical method than were found by the biochemical method (10%). Benign breast disease was also studied using the fluorescent cytochemical method. A greater proportion of lesions containing estrogen receptors was found compared with that cited in the literature for the competitive protein-binding assay. Because of the methodologic simplicity of the fluorescent cytochemical method, further study for routine use is indicated.

Dysphagia associated with cricopharyngeal dysfunction

In protracted forms of dysphagia associated with neuromuscular dysfunction, myotomy of the upper esophageal sphincter has been suggested. The literature, however, is unclear about the indications and outcome of this procedure. In this article, 3 cases are presented of dysphagia associated with the failure of relaxation of the cricopharyngeus during swallowing. Two patients had brain stem infarctions and the 3rd had an inflammatory disease of the brain stem. In all patients, barium swallow revealed aspiration of contrast material into the trachea with failure of relaxation of the cricopharyngeal sphincter. Indirect laryngoscopy demonstrated partial paralysis of one or both vocal cords. In one, an emg of the laryngeal muscles showed normal results. A complete evaluation by the speech pathologist failed to reveal abnormality of the oral musculature in all patients. All patients required gastrostomies for their nutritional needs. Therapeutic modification and control of rate, quantity and consistency of food along with counseling for prevention of aspiration. Oral feeding, without aspiration, was achieved in the 3 patients within the treatment period, allowing removal of the gastrostomy. Cricopharyngeal myotomy, therefore, was not necessary in these patients, despite the long duration of the swallowing problem.