Increasing Mental Health Screening in Pediatric Subspecialty Clinics: An Improvement Project at Brooke Army Medical Center

INTRODUCTION

Mental health screening allows for the early identification of patients at risk of mental health disorders such as anxiety and depression. The Defense Health Administration Procedures Manual 6025.01 established that patients older than 12 years of age should receive annual mental health screening assessing suicidality risk with a standardized screening tool.

MATERIALS AND METHODS

To improve rates of mental health screening in this at-risk population, an A3 Lean approach to quality improvement was undertaken in the Pediatric Subspecialty Clinics at Brooke Army Medical Center.

RESULTS

Baseline data of Patient Health Questionnaire-9 or General Anxiety Disorder-7 screening from pediatric pulmonology and cardiology clinics were 6.3%. Plan-Do-Study-Act quality improvement methods evaluated possible interventions to improve screening. A standard operating procedure (SOP) outlining scoring and interpretation recommendations was distributed in pediatric pulmonology and cardiology clinics. Using the Armed Forces Health Longitudinal Technology Application, a post-implementation chart review was conducted for 8 weeks. With the initiation of Military Health System Genesis, the SOP was adjusted and a root cause analysis was performed. The pediatric gastroenterology clinic cares for patients presenting with functional abdominal pain; therefore, the clinic was added to the second iteration to determine if anxiety or depression may play a role. Providers were educated on documentation and coding. A second post-implementation chart review was conducted for 8 weeks. Over two iterations, mental health screening of new adolescent patients in pediatric subspecialty clinics increased by 794% from baseline. Our providers screened 50% of the adolescent patients.

CONCLUSIONS

With increased surveillance of an at-risk population, more adolescents will receive the standard of care. With refinement of the SOP and expansion to other subspecialties, this project has the potential to expand within Brooke Army Medical Center and other clinics in the Defense Health Administration.

Computational framework for the generation of one-dimensional vascular models accounting for uncertainty in networks extracted from medical images

One-dimensional (1D) cardiovascular models offer a non-invasive method to answer medical questions, including predictions of wave-reflection, shear stress, functional flow reserve, vascular resistance, and compliance. This model type can predict patient-specific outcomes by solving 1D fluid dynamics equations in geometric networks extracted from medical images. However, the inherent uncertainty in in-vivo imaging introduces variability in network size and vessel dimensions, affecting hemodynamic predictions. Understanding the influence of variation in image-derived properties is essential to assess the fidelity of model predictions. Numerous programs exist to render three-dimensional surfaces and construct vessel centerlines. Still, there is no exact way to generate vascular trees from the centerlines while accounting for uncertainty in data. This study introduces an innovative framework employing statistical change point analysis to generate labeled trees that encode vessel dimensions and their associated uncertainty from medical images. To test this framework, we explore the impact of uncertainty in 1D hemodynamic predictions in a systemic and pulmonary arterial network. Simulations explore hemodynamic variations resulting from changes in vessel dimensions and segmentation; the latter is achieved by analyzing multiple segmentations of the same images. Results demonstrate the importance of accurately defining vessel radii and lengths when generating high-fidelity patient-specific hemodynamics models.

PSI-4 Investigation of a Naturally Occurring XX Male Bull

The Y chromosome–linked gene sex-determining region (SRY) is believed to be the master initiator of male sex determination in almost all eutherian mammals, functioning to upregulate expression of its direct target gene SRY-related HMG box–containing gene 9 (SOX9). XX maleness in humans is a rare syndrome with a frequency of 1 in 20,000–25,000 males. Approximately 90% of these cases carry some amount of the Y chromosome sequences due to an illegitimate recombination between X and Y chromosomes, where most of these cases have normal male genitalia. A more severe manifestation, the remaining 10% do not have any Y-chromosome sequences, and typically have ambiguous genitalia. In this study, we report a case of an infertile bull. Physical examination of this purebred Holstein bull showed a phenotypically androgynous animal with a normal penis, cryptorchidism (2 diminutive testicles, only one descended), and with a skeletal conformation and stance usually associated with female individuals. Lymphocytes from heparin sodium anticoagulated blood were cultured, harvested, and prepared according to conventional cell culture methods revealed a normal 60, XX karyotype with no numerical or structural chromosomal aberrations. PCR analyses were negative for the SRY gene, and positive for androgen receptor gene on the X chromosome. No sperm were found in seminal fluid collected in a routine breeding soundness exam at 17 months of age. The bull was slaughtered at 18 months of age, and its reproductive tract was collected. The testicle weighed 18.9 g (descended), and 42.4 g (abdominal). Neither testicle/epididymal unit was appropriate size or fully developed. Two very enlarged vesicular glands (43.36 g and 52.52 g, normally each ~ 20 g) were observed alongside what appeared to be uterine tissue. Histology showed no tubular grooves in the ampulla and an epididymis devoid of sperm. The development of a male phenotype in SRY-negative XX individuals suggests that in addition to SRY, there are autosomal or X-linked genes involved in the sex-determining pathway. In humans, a dose change of the SOX9 gene, loss of function mutations in the WNT4, FoxL2, and RSPO1 testicular suppressing genes, and genomic rearrangements within the regulatory region of the SRY-box transcription factor 3 (SOX3) gene have all been associated with XX male sex reversal. To investigate whether a mutation or genomic rearrangement was responsible for the male phenotype in the SRY-negative 60, XX bull, DNA was collected from the bull and his sire and dam for long-read trio sequencing. These data may provide evidence for either a loss of function mutation in a gene normally inhibiting testes formation in XX individuals, or a gain of function mutation in a gene downstream of SRY in the sex determining pathway.

169 Comparison of pregnancy outcomes in dairy heifers artificially inseminated with sexed semen deposited in the uterine horns versus the uterine body

The use of sexed semen (SS) for AI of cattle has resulted in lower pregnancy per timed AI (P/TAI) compared with conventional semen. This has been attributed to lower sperm dose and cell damage during the cell sorting-freezing process. Horn AI is a common practice in equines and canines to improve pregnancy rate when using low sperm doses. The objective was to compare P/TAI and pregnancy loss (PL) in dairy heifers inseminated with SS deposited in the uterine horn (UH) ipsilateral to the ovary containing the preovulatory follicle (POF) versus TAI in the uterine body (UB). This study was performed on two dairy farms in Georgia (A and B). On farm A, 74 Holstein heifers (12 months old) received a 5-day Cosynch + controlled internal drug release (CIDR) protocol including an intravaginal insert (Eazi-Breed CIDR, Zoetis Animal Health) containing 1.38g of progesterone for 5 days and a dose of gonadotrophin-releasing hormone (GnRH) intramuscularly (100µg, 2mL of Factrel, Zoetis Animal Health). At CIDR removal, heifers received a dose of prostaglandin F2α (PGF2α) intramuscularly (25mg, 5mL of Lutalyse, Zoetis Animal Health) and again 24h later; 72h after CIDR removal, heifers received 100µg of GnRH intramuscularly and TAI with frozen-thawed SS. On farm B, 237 Holstein×Jersey heifers (12 months old) received a modified 5-day Cosynch + CIDR. This protocol was similar to that on farm A but did not include GnRH at the time of CIDR insertion or a second dose of PGF2α 24h after CIDR removal. Immediately before TAI, heifers were examined using transrectal ultrasonography (TRUS) to determine on which ovary the POF was present. Each heifer was randomly assigned to TAI using SS in either the UH ipsilateral to the ovary containing the POF (n=150; farm A, n=32; farm B, n=118) or the UB regardless of where the POF was identified (n=161; farm A, n=42; farm B, n=119). Pregnancy was diagnosed 32 days after TAI using TRUS to determine P/TAI. Heifers diagnosed pregnant were re-examined using TRUS at 60 days of gestation to assess PL. Data were analysed using PROC LOGISTIC and the chi-square test of SAS (SAS Institute Inc.). Heifers that received SS in the UH had adequate P/TAI (50.6% (76/150); farm A: 50.0% (16/32); farm B: 50.8% (60/118)), which tended to be numerically greater (P=0.12) than that observed in heifers receiving SS in the UB (43.4% (70/161); farm A: 40.5% (17/42); farm B: 44.5% (53/119)). In addition, PL was not different between groups and was within normal ranges for dairy heifers (10.0 and 9.4% for UH and UB, respectively). In conclusion, TAI of dairy heifers with SS deposited in the UH ipsilateral to the ovary containing the POF resulted in adequate P/TAI, which was 7.2% greater than TAI in the UB. Horn AI with SS might become a valuable tool for optimising reproductive efficiency and genetic selection of dairy herds.

The pervasive effects of lighting environments on sensory drive in bluefin killifish: an investigation into male/male competition, female choice, and predation

Sensory drive predicts that the conditions under which signaling takes place have large effects on signals, sensory systems, and behavior. The coupling of an ecological genetics approach with sensory drive has been fruitful. An ecological genetics approach compares populations that experience different environments and asks whether population differences are adaptive and are the result of genetic and/or environmental variation. The multi-faceted effects of signaling environments are well-exemplified by the bluefin killifish. In this system, males with blue anal fins are abundant in tannin-stained swamps that lack UV/blue light but are absent in clear springs where UV/blue light is abundant. Past work indicates that lighting environments shape genetic and environmental variation in color patterns, visual systems, and behavior. Less is known about the selective forces creating the across population correlations between UV/blue light and the abundance of blue males. Here, we present three new experiments that investigate the roles of lighting environments on male competition, female mate choice, and predation. We found strong effects of lighting environments on male competition where blue males were more likely to emerge as dominant in tea-stained water than in clear water. Our preliminary study on predation indicated that blue males may be less susceptible to predation in tea-stained water than in clear water. However, there was little evidence for female preferences favoring blue males. The resulting pattern is one where the effects of lighting environments on genetic variation and phenotypic plasticity match the direction of selection and favor the expression of blue males in swamps.

The Combined Elevation Test (CET) in Adolescent School Children: A Pilot Study

The Combined Elevation Test (CET) is a musculoskeletal screening technique (MST) that replicates the streamline position in swimming and is commonly used in various sports. Although CET is widely used, no normative data exist within an adolescent population. Therefore, the purpose of this study was to develop a large data set for the CET within an adolescent population and to evaluate the influence of various demographic and anthropometric variables. Data were collected for 416 participants aged between 8 and 18 years old. Age and arm span showed a significant correlation with CET scores (arm span r_s (105) = 0.478, p = 0.000; age r_s (416) = 0.238, p = 0.000). Regression analysis further quantified the influence of arm span and age on CET scores, accounting for 23.1% and 5.3% of variability respectively. These results can be used as a reference point for clinicians and coaches who are using the CET within their assessments.

Oral budesonide as a therapy for protein-losing enteropathy in patients having undergone Fontan palliation

BACKGROUND

  Protein-losing enteropathy is associated with Fontan palliation for single-ventricle physiology and has been difficult to treat. Limited data suggest the successful use of oral budesonide (Entocort, AstraZeneca) as a palliative measure.

METHODS

  We examine our single-institution retrospective experience in eight patients who were treated with this therapy.

RESULTS

  Median pretherapy albumin level was 1.7 g/dL (range 1.0-2.7 g/dL), 3 months after therapy was 3.1 g/dL (range 2-4.8 g/dL), and by the end of the first year was 3.4 g/dL (range 2.1-5.3 g/dL). All patients had at least a transient improvement, and at latest follow-up (median 29 months, range 3-51 months) five patients remain on therapy. Five of eight patients had required pretherapy albumin transfusions; one patient required albumin infusions after therapy. Four patients had side effects associated with the medication.

CONCLUSIONS

  Oral budesonide is an additional therapy that has the potential to improve symptoms and delay need for heart transplantation in this patient population.

Physiological roles of glutathione s-transferases in soybean root nodules

Glutathione S-transferases (GSTs) are ubiquitous enzymes that catalyze the conjugation of toxic xenobiotics and oxidatively produced compounds to reduced glutathione, which facilitates their metabolism, sequestration, or removal. We report here that soybean (Glycine max) root nodules contain at least 14 forms of GST, with GST9 being most prevalent, as measured by both real-time reverse transcription-polymerase chain reaction and identification of peptides in glutathione-affinity purified extracts. GST8 was prevalent in stems and uninfected roots, whereas GST2/10 prevailed in leaves. Purified, recombinant GSTs were shown to have wide-ranging kinetic properties, suggesting that the suite of GSTs could provide physiological flexibility to deal with numerous stresses. Levels of GST9 increased with aging, suggesting a role related to senescence. RNA interference studies of nodules on composite plants showed that a down-regulation of GST9 led to a decrease in nitrogenase (acetylene reduction) activity and an increase in oxidatively damaged proteins. These findings indicate that GSTs are abundant in nodules and likely function to provide antioxidant defenses that are critical to support nitrogen fixation.