Acute downregulation of emerin alters actomyosin cytoskeleton connectivity and function

Fetal lung fibroblasts contribute dynamic infrastructure for the developing lung. These cells undergo dynamic mechanical transitions, including cyclic stretch and spreading, which are integral to lung growth in utero. We investigated the role of the nuclear envelope protein emerin in cellular responses to these dynamic mechanical transitions. In contrast to control cells, which briskly realigned their nuclei, actin cytoskeleton, and extracellular matrices in response to cyclic stretch, fibroblasts that were acutely downregulated for emerin showed incomplete reorientation of both nuclei and actin cytoskeleton. Emerin-downregulated fibroblasts were also aberrantly circular in contrast to the spindle-shaped controls and exhibited an altered pattern of filamentous actin organization that was disconnected from the nucleus. Emerin knockdown was also associated with reduced myosin light chain phosphorylation during cell spreading. Interestingly, emerin-downregulated fibroblasts also demonstrated reduced fibronectin fibrillogenesis and production. These findings indicate that nuclear-cytoskeletal coupling serves a role in the dynamic regulation of cytoskeletal structure and function and may also impact the transmission of traction force to the extracellular matrix microenvironment.

The Utility and Impact of the Painful Periods Screening Tool (PPST) to Improve Healthcare Delivery for People with Symptoms of Pelvic Pain

The objective of this study was to evaluate the utility and impact of the Painful Periods Screening Tool (PPST) to improve healthcare delivery for people with symptoms of pelvic pain. The design of this study was a survey study. After IRB approval, patients aged 18-55 years with self-reported pelvic, abdominal, or lower back pain before, during, or after menstrual periods were invited to participate in the study from September 2020 to June 2021. Participants filled out the PPST questionnaire on the day of their Johns Hopkins clinic visit and the follow-up questionnaire 1-14 days after the clinic visit. Demographics and duration of pain were assessed, and participants who completed the PPST questionnaire were sent a follow-up questionnaire to assess utility and impact of PPST. Of the 1352 patients who met study eligibility, 1000 participants responded to both questionnaires. Most subjects (82.9%; 95% CI: 80.4-85.2%) reported having severe pelvic/abdominal or lower back pain during menses. Nine hundred fifteen participants (91.5%; 95% CI: 89.6-93.2%) reported that if given regularly, the PPST would help women discuss their pain symptoms with their healthcare provider. Six hundred seventy-eight participants (67.8%; 95% CI: 64.8-70.7%) reported that the PPST helped them initiate a conversation about their symptoms. Seven hundred seven participants (70.7%; 95% CI: 67.8-73.5%) were more comfortable discussing symptoms of pelvic pain with their provider after filling out the PPST. These findings support the utility of PPST as an endometriosis screening tool and suggest that this tool facilitated communication between patients and providers about pain symptoms.

Longitudinal comparisons of a whole-mouth taste test to clinician-rated and patient-reported outcomes of dysgeusia postradiotherapy in patients with head and neck cancer and associations with oral intake

BACKGROUND

After head and neck cancer (HNC) treatment, dysgeusia may be a barrier to oral intake. In this exploratory study, we prospectively examined taste perception, clinician-rated (CRO) and patient-reported (PRO) taste changes and their effect on oral intake postradiotherapy.

METHODS

Twenty-eight patients were assessed at baseline, treatment weeks 2 and 4, and 1, 3, and 6 months post-treatment using a whole-mouth taste test and associated CRO and subjective PRO measures.

RESULTS

Greater taste impairment was reflected by subjective than by a whole-mouth taste test. The most significant and consistent decline occurred mid-treatment. The Chemotherapy-Induced Taste Alteration Scale (PRO) discomfort subscale correlated significantly with maintaining an oral diet, percent of oral intake, and appetite level from mid-treatment to 6 months post-treatment.

CONCLUSIONS

PRO results indicated ongoing oral intake issues. Whole-mouth taste tests may fail to fully reflect functional taste-loss. Dysgeusia prevention and treatment methods are needed to improve patient outcomes.

Improvements in Physician Clinical Workflow Measures After Implementation of a Dashboard Program

PURPOSE

To determine whether a combination of data-driven, personalized feedback and implementation of a graduated, sequential intervention model improved key measures of physician workflow and quality in radiation treatment planning.

METHODS AND MATERIALS

All radiation oncologists across 3 facilities at a single academic institution were prospectively evaluated on 5 predefined metrics of timeliness and accuracy in the treatment-planning process using a web-based institutional data repository and an institutional incident learning system. The study period encompassed 10 quarters from 2014 to 2016, with 2013 serving as a retrospective baseline. Physicians received quarterly individualized reports of their compliance metrics (a practice labeled the Physician Dashboard), and administrative interventions were initiated if >20% noncompliance with any metric was exceeded within a quarter. Consecutive quarters of noncompliance resulted in escalating interventions, including progress meetings with department leadership, and culminated in financial penalties. Rates of noncompliance were compared before and after implementation of this model.

RESULTS

Three thousand six hundred sixty pre-Dashboard and 9497 post-Dashboard simulations were analyzed. After Dashboard implementation, significant reductions were observed in the rates of simulation orders requiring signature by a covering physician (14.1% vs 7.4%, P < .001), and the submission of plan contours ≥1 day (43.1% vs 23.1%, P < .001) or ≥2 days (30.8% vs 18.3%, P = .002) after the due date. There was some decrease in rates of inaccurate or incomplete plan submissions (6.2% vs 3.9%, P = .08). Seven of the 12 physicians received at least 1 intervention, with only 2 receiving all levels of intervention.

CONCLUSIONS

Regular assessment and targeted feedback using the Physician Dashboard significantly improved radiation oncologist compliance with clinically meaningful treatment planning responsibilities at a high-volume academic center.

Approaches to Measuring Trends in Interdisciplinary Research Publications at One Academic Medical Center

PURPOSE

To determine if interdisciplinary research has increased between 2005 and 2015, based on an analysis of journal articles containing at least 1 author from Johns Hopkins University, and to compare different methods for determining the disciplinarity of research articles.

METHOD

In 2017-2018, 100 peer-reviewed biomedical science articles were randomly selected from years 2005, 2010, and 2015 and classified as unidisciplinary or interdisciplinary based on Scopus author affiliation data (method 1). The corresponding authors of the 2010 and 2015 articles were sent a survey asking them to describe the disciplines involved in their research (method 2) and to define their research as unidisciplinary or interdisciplinary based on provided definitions (method 3).

RESULTS

There was a statistically significant increase in the proportion of interdisciplinary articles in 2015 compared with both 2005 and 2010 (P = .02). Comparison of the 3 methods indicated that 45% of the articles were classified as interdisciplinary based on author affiliation data (method 1), 40% based on the corresponding author's description of the disciplines involved in their research (method 2), and 71% based on the corresponding author's definition of their article's disciplinarity (method 3). There was a statistically significant difference in the proportion of articles classified as interdisciplinary between methods 1 and 3 (P < .001) and between methods 2 and 3 (P < .001).

CONCLUSIONS

This study found that interdisciplinary research increased at Johns Hopkins University over the past decade and highlights the difference between corresponding authors' views of their own research and other methods for determining interdisciplinarity.

Third Ventricle Obstruction by Thalamic Intracerebral Hemorrhage Predicts Poor Functional Outcome Among Patients Treated with Alteplase in the CLEAR III Trial

INTRODUCTION

The Clot Lysis: Evaluating Accelerated Resolution of IVH trial examined whether irrigating the ventricular system with alteplase improved functional outcomes in patients with small intracerebral hemorrhage (ICH) and large intraventricular hemorrhage (IVH). Thalamic ICH location was common and was associated with poor outcome. One possible explanation is thalamic ICH-associated mass effect obstructing the third ventricle. We hypothesized that patients with thalamic ICH obstructing the third ventricle would have worse functional outcomes compared to patients without obstructing lesions.

METHODS

ICH obstruction of third ventricle was defined as third ventricle compression on 1 or more axial computed tomography slices visually impeding cerebral spinal fluid flow. If the third ventricle was casted with IVH, it was scored as such. Multivariable logistic regression analyses were used to determine whether obstruction of the third ventricle predicts poor functional outcomes defined as modified Rankin score (mRS) 4-6, higher mRS, and mortality at 180 days. Models were adjusted for thalamic ICH location, ICH volume, IVH volume, age, hydrocephalus, baseline Glasgow coma scale, and percentage of low cerebral perfusion pressures during treatment.

RESULTS

Among saline-treated patients, obstruction of the third ventricle by IVH was a significant predictor of higher mRS at 180 days (OR 1.87, CI 1.01-3.47) and mortality at 180 days (OR 2.73, CI 1.27-5.87) while obstruction by ICH was not. In contrast, among alteplase-treated patients, obstruction by ICH was a significant predictor of mRS 4-6 (OR 3.20, CI 1.30-7.88) and higher mRS at 180 days (OR 2.33, CI 1.24-4.35), while obstruction by IVH was not.

CONCLUSIONS

Poor outcomes were associated with mass-related obstruction of the third ventricle from thalamic ICH in alteplase-treated patients and from IVH in saline-treated patients. Once the ventricular system is cleared with alteplase, obstruction of cerebral spinal fluid flow from thalamic ICH might become important in functional recovery.

Alcohol Use Patterns and Subsequent Sexual Behaviors Among Women, Men who have Sex with Men and Men who have Sex with Women Engaged in Routine HIV Care in the United States

Among people with HIV, alcohol use is associated with increased prevalence of sexual transmission behaviors. We examined associations between alcohol use in the prior year and sexual behaviors approximately six months later among 1857 women, 6752 men who have sex with men (MSM) and 2685 men who have sex with women (MSW). Any alcohol use was associated with increased risk of unsafe vaginal sex among women; anal sex and =>2 anal sex partners among MSM; and anal sex, =>2 anal or vaginal sex partners, and unsafe vaginal sex among MSW. In particular, among women >7 alcoholic drinks/week and among MSW =>5 alcoholic drinks/drinking day increased the likelihood of certain subsequent sexual behaviors. For all groups, especially women, the risk of sex under the influence of drugs/alcohol markedly increased with increases in quantity and frequency of alcohol consumption. These different patterns of drinking and sexual behaviors indicate the importance of tailored counseling messages to women, MSM and MSW.

A randomized 500-subject open-label phase 3 clinical trial of minimally invasive surgery plus alteplase in intracerebral hemorrhage evacuation (MISTIE III)

RATIONALE AND HYPOTHESIS

Surgical removal of spontaneous intracerebral hemorrhage may reduce secondary destruction of brain tissue. However, large surgical trials of craniotomy have not demonstrated definitive improvement in clinical outcomes. Minimally invasive surgery may limit surgical tissue injury, and recent evidence supports testing these approaches in large clinical trials.

METHODS AND DESIGN

MISTIE III is an investigator-initiated multicenter, randomized, open-label phase 3 study investigating whether minimally invasive clot evacuation with thrombolysis improves functional outcomes at 365 days compared to conservative management. Patients with supratentorial intracerebral hemorrhage clot volume ≥ 30 mL, confirmed by imaging within 24 h ofknown symptom onset,and intact brainstem reflexes were screened with a stability computed tomography scan at least 6 h after diagnostic scan. Patients who met clinical and imaging criteria (no ongoing coagulopathy; no suspicion of aneurysm, arteriovenous malformation, or any other vascular anomaly; and stable hematoma size on consecutive scans) were randomized to either minimally invasive surgery plus thrombolysis or medical therapy. The sample size of 500 was based on findings of a phase 2 study.

STUDY OUTCOMES

The primary outcome measure is dichotomized modified Rankin Scale 0-3 vs. 4-6 at 365 days adjusting for severity variables. Clinical secondary outcomes include dichotomized extended Glasgow Outcome Scale and all-cause mortality at 365 days; rate and extent of parenchymal blood clot removal; patient disposition at 365 days; efficacy at 180 days; type and intensity of ICU management; and quality of life measures. Safety was assessed at 30 days and throughout the study.

Patterns of Decline in Naming and Semantic Knowledge in Primary Progressive Aphasia

BACKGROUND

Individuals with primary progressive aphasia (PPA) and their caregivers want to know what to expect so that they can plan support appropriately. The ability to predict decline in naming and semantic knowledge, and advise individuals with PPA and their caregivers regarding future planning, would be invaluable clinically.

AIMS

The aims of this study were to investigate patterns of decline in naming and semantic knowledge in each of the clinical variants of PPA (logopenic variant PPA, lvPPA; nonfluent agrammatic PPA, nfaPPA; and semantic variant PPA, svPPA) and to examine the effects of other variables on rate of decline. We hypothesized that speech-language rehabilitation, higher education, and higher baseline test scores would be associated with slower decline, and older age with faster decline.

METHODS AND PROCEDURES

A total of ninety-four participants with PPA underwent language testing, including thirty six participants with lvPPA, thirty-one participants with nfaPPA, and twenty-seven participants with svPPA. All participant groups were similar in age and education. We focused on decline on three tests: the short form of the Boston Naming Test (BNT), the Hopkins Assessment of Naming Actions (HANA), and the short form of the Pyramids and Palm Trees Test (PPTT).

OUTCOME AND RESULTS

Across language tests, the most precipitous rates of decline (loss of points per month) occurred in nfaPPA, followed by svPPA, then lvPPA. Female sex, longer symptom duration, higher baseline test score, and speech-language rehabilitation were associated with slower decline.

CONCLUSIONS

PPA variants were distinguishable by rapidity of decline, with nfaPPA having the most precipitous decline. As hypothesized, higher baseline test scores and speech-language rehabilitation were associated with slower decline. Surprisingly, age and education were not important prognostically for individuals in this study. Further study of prognostically-relevant variables in PPA is indicated in this population.

Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes

Head and neck cancer (HNC) guidelines recommend regular multidisciplinary team (MDT) monitoring and early intervention to optimize dysphagia outcomes; however, many factors affect the ability to achieve these goals. The aims of this study were to explore the barriers/facilitators to establishing and sustaining a MDT HNC care pathway and to examine the dysphagia-related speech-language pathology (SLP) and dietetic components of the pathway. Using the Consolidated Framework for Implementation Research (CFIR), a mixed methods study design was used to evaluate an established MDT HNC pathway. Ten MDT members provided perceptions of facilitators/barriers to implementing and sustaining the pathway. Patients attending the SLP and dietetic components of the pathway who commenced treatment between 2013 and 2014 (n = 63) were audited for attendance, outcome data collected per visit, and swallowing outcomes to 24-month post-treatment. Dysphagia outcomes were compared to a published cohort who had received intensive prophylactic dysphagia management. Multiple CFIR constructs were identified as critical to implementing and sustaining the pathway. Complexity was a barrier. Patient attendance was excellent during treatment, with low rates of non-compliance (< 15%) to 24 months. Collection of clinician/patient outcome tools was good during treatment, but lower post-treatment. Dysphagia outcomes were good and comparable to prior published data. The pathway provided patients with access to regular supportive care and provided staff opportunities to provide early and ongoing dysphagia monitoring and management. However, implementing and sustaining a HNC pathway is complex, requiring significant staff resources, financial investment, and perseverance. Regular audits are necessary to monitor the quality of the pathway.

Abstract WP338: Effect of Thalamic Hemorrhage Localization on Level of Consciousness and Functional Outcomes in the CLEAR III Trial

Introduction: Thalamic hemorrhages account for 10-15% of intracerebral hemorrhages (ICH) and have a variety of clinical manifestations. We investigated the relationship between injury to thalamus and intra-thalamic regions with level of consciousness and functional outcomes among CLEAR-III trial participants.

Methods: We analyzed diagnostic CT scans of 500 patients from CLEAR-III trial prior to randomization and identified the anatomic localization of ICH. Thalamic hemorrhages were further divided into 5 groups: dorsal, anterior, medial, central, and posterolateral. Blinded level of consciousness measures (Glasgow Coma Score (GCS) and question 1a of the National Institutes of Health Stroke Scale (NIHSS)) and stroke severity indices (including mortality and modified Rankin Scale (mRS)) were analyzed. We assessed association of each region with level of consciousness and stroke severity measures using multivariate logistic regression models. Major disability was defined as mRS 4-5. Outcome models were adjusted for ICH volume, IVH (intraventricular hemorrhage) volume, and age.

Results: Thalamic ICH was present in 332 patients (71%, 33 with primary IVH were excluded). Initial median GCS was similar in patients with (10, IQR 7-14) and without (10, IQR 6-14) thalamic lesion (P=0.72). At day 30 and 180, thalamic ICH was associated with increased mortality (OR 2.48, CI 0.92-6.63 and OR 2.03, CI 1.02-4.06), major disability (OR 2.44, CI 0.87-6.81 and OR 2.50, CI 1.08-5.75), and death or major disability (OR 2.57, CI 0.91-7.19 and OR 2.71, CI 1.37-5.38), respectively. Thalamic ICH involved medial, central, posterolateral, dorsal, and anterior regions in 51.8%, 48.8%, 48.6%, 56.8%, and 47% of cases, respectively. On day 7, only involvement of the medial thalamus was associated with decreased consciousness defined as GCS <=8 and NIHSS question 1a>=2 (P=0.024 and 0.043, respectively). While all thalamic regions were associated with worse mRS, none were associated with decreased consciousness at day 180.

Conclusion: Thalamic hemorrhages are associated with poor functional outcomes. Medial thalamus involvement affects consciousness acutely but not in the long term. The mechanism by which medial thalamus alters consciousness merits investigation.

Differentiating between subtypes of primary progressive aphasia and mild cognitive impairment on a modified version of the Frontal Behavioral Inventory

Behavioral assessment has been investigated in frontotemporal lobar degeneration and Alzheimer's disease, but has not been explored extensively in subtypes of primary progressive aphasia (PPA). We explored the ability of a modified version of the Frontal Behavioral Inventory (FBI-mod) to discriminate between patients with distinct subtypes of PPA and patients with mild cognitive impairment (MCI). We hypothesized that individuals with nonfluent agrammatic PPA (nfaPPA) would have higher negative behavior scores than other groups and that individuals with semantic variant PPA (svPPA) would have higher disinhibition scores than other groups. Family members and/or caregivers of 120 individuals with PPA and MCI (mean age 69.54+8.75 years; 65 (54%) female; education 16.06±2.68 years; disease duration 46.47±34.26 months) completed the FBI-mod [logopenic PPA (lvPPA) n = 40. nfaPPA n = 29, svPPA n = 27, MCI n = 24]. The groups were not significantly different in age, gender, education, or disease duration. There were no significant differences between the groups for negative behaviors (p = 0.72) and disinhibition scores (p = 0.14). When comparing negative and disinhibition scores (in percent), negative scores were significantly higher in all groups (p < 0.001). When comparing subtest items, there was a pairwise difference between lvPPA and svPPA for restlessness (lvPPA < svPPA, p = 0.02, after adjusting for multiple between-group comparisons). There was a significant difference in the proportion of severe neglect between the groups with lvPPA having a lower proportion than the other two variants (p = 0.05), and there was a significant difference in the proportion of severe poor judgment between the groups with lvPPA also having a lower proportion than nfaPPA (p = 0.04). This study reveals the greater negative behavioral disturbance than disinhibition in the PPA and MCI groups of similar age and duration since onset and identifies different profiles for some specific behaviors for the PPA groups. These findings may have clinical and practical implications.

Association between self-reported sexually transmitted infection treatment and mental health symptoms in conflict-affected eastern Democratic Republic of the Congo

Although poor mental health has been associated with sexual risk behavior, few studies have examined the association between mental health and sexually transmitted infections (STIs) in conflict-affected settings. With elevated symptoms of poor mental health in conflict-affected settings, it is important to consider if and how mental health may be a risk factor for STIs in these settings. We used cross-sectional logistic regression to examine the association between symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD) with having been treated for an STI in rural South Kivu, Democratic Republic of the Congo. Among 753 adults, those with elevated self-reported symptoms of depression and anxiety (adjusted OR = 2.73, 95% CI 1.68, 4.44) and PTSD (adjusted OR = 1.89, 95% CI 1.17, 3.06) had higher odds of reporting ever being treated for an STI than those who were not symptomatic. Our findings suggest that future studies are needed to more rigorously examine the relationship between mental health and STIs.

Effects of Obesity and Leptin Deficiency on Morphine Pharmacokinetics in a Mouse Model

BACKGROUND

Obesity causes multiorgan dysfunction, specifically metabolic abnormalities in the liver. Obese patients are opioid-sensitive and have high rates of respiratory complications after surgery. Obesity also has been shown to cause resistance to leptin, an adipose-derived hormone that is key in regulating hunger, metabolism, and respiratory stimulation. We hypothesized that obesity and leptin deficiency impair opioid pharmacokinetics (PK) independently of one another.

METHODS

Morphine PK were characterized in C57BL/6J wild-type (WT), diet-induced obese (DIO), and leptin-deficient (ob/ob) mice, and in ob/ob mice given leptin-replacement (LR) therapy. WT mice received several dosing regimens of morphine. Obese mice (30 g) received one 80 mg/kg bolus of morphine. Blood was collected at fixed times after morphine injection for quantification of plasma morphine and morphine 3-glucuronide (M3G) levels. PK parameters used to evaluate morphine metabolism included area-under the curve (AUC150), maximal morphine concentration (CMAX), and M3G-to-morphine ratio, and drug elimination was determined by clearance (Cl/F), volume of distribution, and half-life (T1/2). PK parameters were compared between mouse groups by the use of 1-way analysis of variance, with P values less than .05 considered significant.

RESULTS

DIO compared with WT mice had significantly decreased morphine metabolism with lower M3G-to-morphine ratio (mean difference [MD]: -4.9; 95% confidence interval [CI]: -8.8 to -0.9) as well as a decreased Cl/F (MD: -4.0; 95% CI: -8.9 to -0.03) Ob/ob compared with WT mice had a large increase in morphine exposure with a greater AUC150 (MD: 980.4; 95% CI: 630.1-1330.6), CMAX (MD: 6.8; 95% CI: 2.7-10.9), and longer T1/2 (MD: 23.1; 95% CI: 10.5-35.6), as well as a decreased Cl/F (MD: -7.0; 95% CI: -11.6 to -2.7). Several PK parameters were significantly greater in ob/ob compared with DIO mice, including AUC150 (MD: 636.4; 95% CI: 207.4-1065.4), CMAX (MD: 5.3; 95% CI: 3.2-10.3), and T1/2 (MD: 18.3; 95% CI: 2.8-33.7). When leptin was replaced in ob/ob mice, PK parameters began to approach DIO and WT levels. LR compared with ob/ob mice had significant decreases in AUC150 (MD: -779.9; 95% CI: -1229.8 to -330), CMAX (MD: -6.1; 95% CI: -11.4 to -0.9), and T1/2 (MD: -19; 95% CI: -35.1 to -2.8). Metabolism increased with LR, with LR mice having a greater M3G-to-morphine ratio compared with DIO (MD: 5.3; 95% CI: 0.3-10.4).

CONCLUSIONS

Systemic effects associated with obesity decrease morphine metabolism and excretion. A previous study from our laboratory demonstrated that obesity and leptin deficiency decrease the sensitivity of central respiratory control centers to carbon dioxide. Obesity and leptin deficiency substantially decreased morphine metabolism and clearance, and replacing leptin attenuated the PK changes associated with leptin deficiency, suggesting leptin has a direct role in morphine metabolism.

Anesthesiologists and Disaster Medicine: A Needs Assessment for Education and Training and Reported Willingness to Respond

BACKGROUND

Anesthesiologists provide comprehensive health care across the emergency department, operating room, and intensive care unit. To date, anesthesiologists' perspectives regarding disaster medicine and public health preparedness have not been described.

METHODS

Anesthesiologists' thoughts and attitudes were assessed via a Web-based survey at 3 major academic institutions. Frequencies, percentages, and odds ratios (ORs) were used to assess self-reported perceptions of knowledge and skills, as well as attitudes and beliefs regarding education and training, employee development, professional obligation, safety, psychological readiness, efficacy, personal preparedness, and willingness to respond (WTR). Three representative disaster scenarios (natural disaster [ND], radiological event [RE], and pandemic influenza [PI]) were investigated. Results are reported as percent or OR (95% confidence interval).

RESULTS

Participants included 175 anesthesiology attendings (attendings) and 95 anesthesiology residents (residents) representing a 47% and 51% response rate, respectively. A minority of attendings indicated that their hospital provides adequate pre-event preparation and training (31% [23-38] ND, 14% [9-21] RE, and 40% [31-49] PI). Few residents felt that their residency program provided them with adequate preparation and training (22% [14-33] ND, 16% [8-27] RE, and 17% [9-29] PI). Greater than 85% of attendings (89% [84-94] ND, 88% [81-92] RE, and 87% [80-92] PI) and 70% of residents (81% [71-89] ND, 71% [58-81] RE, and 82% [70-90] PI) believe that their hospital or residency program, respectively, should provide them with preparation and training. Approximately one-half of attendings and residents are confident that they would be safe at work during response to a ND or PI (55% [47-64] and 58% [49-67] of attendings; 59% [48-70] and 48% [35-61] of residents, respectively), whereas approximately one-third responded the same regarding a RE (31% [24-40] of attendings and 28% [18-41] of residents). Fewer than 40% of attendings (34% [26-43]) and residents (38% [27-51]) designated who would take care of their family obligations in the event they were called into work during a disaster. Regardless of severity, 79% (71-85) of attendings and 73% (62-82) of residents indicated WTR to a ND, whereas 81% (73-87) of attendings and 70% (58-81) of residents indicated WTR to PI. Fewer were willing to respond to a RE (63% [55-71] of attendings and 52% [39-64] of residents). In adjusted logistic regression analyses, those anesthesiologists who reported knowing one's role in response to a ND (OR, 15.8 [4.5-55.3]) or feeling psychologically prepared to respond to a ND (OR, 6.9 [2.5-19.0]) were found to be more willing to respond. Similar results were found for RE and PI constructs. Both attendings and residents were willing to respond in whatever capacity needed, not specifically to provide anesthesia.

CONCLUSIONS

Few anesthesiologists reported receiving sufficient education and training in disaster medicine and public health preparedness. Providing education and training and enhancing related employee services may further bolster WTR and help to build a more capable and effective medical workforce for disaster response.

Enhancing Brain Lesions during Acute Optic Neuritis and/or Longitudinally Extensive Transverse Myelitis May Portend a Higher Relapse Rate in Neuromyelitis Optica Spectrum Disorders

BACKGROUND AND PURPOSE

Neuromyelitis optica spectrum disorders are inflammatory demyelinating disorders with optic neuritis and/or longitudinally extensive transverse myelitis episodes. We now know that neuromyelitis optica spectrum disorders are associated with antibodies to aquaporin-4, which are highly concentrated on astrocytic end-feet at the blood-brain barrier. Immune-mediated disruption of the blood-brain barrier may manifest as contrast enhancement on brain MR imaging. We aimed to delineate the extent and frequency of contrast enhancement on brain MR imaging within 1 month of optic neuritis and/or longitudinally extensive transverse myelitis attacks and to correlate contrast enhancement with outcome measures.

MATERIALS AND METHODS

Brain MRIs of patients with neuromyelitis optica spectrum disorders were evaluated for patterns of contrast enhancement (periependymal, cloudlike, leptomeningeal, and so forth). The Fisher exact test was used to evaluate differences between the proportion of contrast enhancement in patients who were seropositive and seronegative for aquaporin-4 antibodies. The Mann-Whitney test was used to compare the annualized relapse rate and disease duration between patients with and without contrast enhancement and with and without seropositivity.

RESULTS

Brain MRIs of 77 patients were evaluated; 59 patients (10 males, 49 females) were scanned within 1 month of optic neuritis and/or longitudinally extensive transverse myelitis attacks and were included in the analysis. Forty-eight patients were seropositive, 9 were seronegative, and 2 were not tested for aquaporin-4 antibodies. Having brain contrast enhancement of any type during an acute attack was significantly associated with higher annualized relapse rates (P = .03) and marginally associated with shorter disease duration (P = .05). Having periependymal contrast enhancement was significantly associated with higher annualized relapse rates (P = .03).

CONCLUSIONS

Brain MRIs of patients with neuromyelitis optica spectrum disorders with contrast enhancement during an acute relapse of optic neuritis and/or longitudinally extensive transverse myelitis are associated with increased annual relapse rates.

Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial

BACKGROUND

Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome.

METHODS

In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators. This study is registered with ClinicalTrials.gov, NCT00784134.

FINDINGS

Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group. The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88-1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90-1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95% CI 0·41-0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22-3·26], p=0·007). Ventriculitis (17 [7%] alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31-0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76 [95% CI 0·64-0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in the saline group; RR 1·21 [95% CI 0·37-3·91], p=0·771) was similar.

INTERPRETATION

In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol-based use of alteplase with extraventricular drain seems safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase produces gains in functional status.

FUNDING

National Institute of Neurological Disorders and Stroke.

Efficacy of parent-delivered behavioral therapy for primary complex motor stereotypies

AIM

Primary complex motor stereotypies (CMS) are persistent, patterned, repetitive, rhythmic movements in young people with typical development. This study evaluated the efficacy of an instructional DVD as a home-based, parent-administered, behavioral therapy for primary CMS.

METHOD

Eighty-one children with primary CMS were enrolled. Primary outcome measures included the Stereotypy Severity Scale (SSS) - Motor and Impairment scores, and Stereotypy Linear Analog Scale (SLAS). Mean CMS onset was 13.4 months (SD 13.1). Eligibility required observed CMS. Psychiatric disorders were not exclusionary and a stable medication regimen was required. Intellectual disability, neurological disorder, autism spectrum disorder, and tics were exclusionary. Initial assessments were completed via REDCap before receipt of the DVD. Fifty-four of the 81 children (34 male, 20 female; mean age 8y 2mo, SD 1.42, range 7-14y) completed assessments at 1, 2, or 3 months after receiving the DVD.

RESULTS

Reductions (baseline to last assessment) in SSS Motor, SSS Impairment, and SLAS scores (all p<0.001) represented change ratios of -15%, -24%, and a -20% respectively. Greatest relative treatment benefit was observed by younger children (ages 7-8y), and by 1 month after receipt of DVD, while a parent global assessment scale showed progressive improvement throughout the study.

INTERPRETATION

An instructional DVD for parent-delivered behavioral therapy was a safe, effective intervention for primary CMS.

Dose-Dependent and Lasting Influences of Intranasal Vasopressin on Face Processing in Men

Arginine vasopressin (AVP) and related peptides have diverse effects on social behaviors in vertebrates, sometimes promoting affiliative interactions and sometimes aggressive or antisocial responses. The type of influence, in at least some species, depends on social contexts, including the sex of the individuals in the interaction and/or on the levels of peptide within brain circuits that control the behaviors. To determine if AVP promotes different responses to same- and other-sex faces in men, and if those effects are dose dependent, we measured the effects of two doses of AVP on subjective ratings of male and female faces. We also tested if any influences persist beyond the time of drug delivery. When AVP was administered intranasally on an initial test day, 20 IU was associated with decreased social assessments relative to placebo and 40 IU, and some of the effects persisted beyond the initial drug delivery and appeared to generalize to novel faces on subsequent test days. In single men, those influences were most pronounced, but not exclusive, for male faces, whereas in coupled men they were primarily associated with responses to female faces. Similar influences were not observed if AVP was delivered after placebo on a second test day. In a preliminary analysis, the differences in social assessments observed between men who received 20 and 40 IU, which we suggest primarily reflect lowered social assessments induced by the lower dose, appeared most pronounced in subjects who carry what has been identified as a risk allele for the V1a receptor gene. Together, these results suggest that AVP's effects on face processing, and possibly other social responses, differ according to dose, depend on relationship status, and may be more prolonged than previously recognized.

Corrigendum: Dose-Dependent and Lasting Influences of Intranasal Vasopressin on Face Processing in Men

[This corrects the article on p. 220 in vol. 8, PMID: 29018407.].

Health-related quality of life before and after head and neck squamous cell carcinoma: Analysis of the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey linkage

BACKGROUND

Understanding health-related quality of life (HRQOL) is crucial to providing high-quality survivorship care for patients with head and neck squamous cell carcinoma (HNSCC). Trends in and prognostic significance of HRQOL before and after HNSCC have not been well described.

METHODS

HRQOL for older individuals with HNSCC was examined using the linked Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey database. Surveys assessing HRQOL from 5 years prediagnosis to 10 years postdiagnosis were included. HRQOL over time was modeled using multilevel linear regression with restricted cubic splines and was reported as either total HRQOL or change in HRQOL (denoted Δ). The association of prediagnosis HRQOL with survival was examined.

RESULTS

In total, 1653 individuals were included; of these, 61% completed 1 survey, and 39% completed multiple surveys. Overall HRQOL decreased progressively until 13 months postdiagnosis, then recovered toward baseline between 2 and 5 years. However, after stratification by survival group, the postdiagnosis recovery was not observed. Individuals with shorter survival had lower HRQOL prediagnosis (<2-year survivors, 87.3; > 5-year survivors, 96.4; P = .004) with a steeper decline in HRQOL during diagnosis and treatment (<2-year survivors: Δ, -16.6; 95% confidence interval [CI], -23.8, -9.4; > 5-year survivors: Δ, -0.9; 95% CI, -1.8, 0.08). Radiotherapy and advanced stage were associated with greater declines in HRQOL during diagnosis and treatment (P < .001). Higher prediagnosis HRQOL was independently associated with improved overall survival (adjusted hazard ratio for 10-point increase, 0.91; 95% CI, 0.85-0.97).

CONCLUSIONS

HRQOL declines before and after HNSCC, whereas any observed posttreatment recovery is likely an artifact of shorter survival among individuals with the lowest HRQOL. The prognostic implication of prediagnosis HRQOL may inform patient counseling. Cancer 2016;122:1861-70. © 2016 American Cancer Society.

Abstract P1-03-09: Pegylated recombinant human hyaluronidase PH20 (PEGPH20) enhances efficacy of eribulin mesylate (HALAVEN®) in triple negative breast cancer xenografts

Hyaluronan (hyaluronic acid, HA), a glycosaminoglycan found in tissue throughout the body, overaccumulates in the tumor microenvironment (TME) of many non-hematologic malignancies, including breast cancer. HA overaccumulation in breast cancer patients correlates with tumor progression and decreased survival (Tammi 2008). Pegylated recombinant human hyaluronidase PH20 (PEGPH20), an investigational therapeutic agent entering Phase 3 clinical development in pancreatic cancer, enzymatically removes HA from the TME. In preclinical animal models, PEGPH20-mediated HA degradation is associated with remodeling of the tumor stroma, reduction of tumor pressure, expansion of tumor blood vessels and facilitated delivery of chemotherapy (Thompson 2010, Provenzano 2012, Jacobetz 2013). Accordingly, preclinical studies investigated the combination of PEGPH20 with eribulin mesylate (ERI, HALAVEN®), a microtubule dynamics inhibitor with a novel mechanism of action (Towle 2001, Jordan 2005), currently approved for treatment of certain patients with advanced breast cancer. NCr nu/nu mice were inoculated subcutaneously with human triple-negative breast cancer (TNBC) HCC1806 or HCC1806/HAS3 cells; the latter subline was engineered to accumulate high HA levels, confirmed by immunohistochemistry, via overexpression of hyaluronan synthase 3 (HAS3). When tumors reached ∼350 mm3, animals were randomly assigned to four treatments groups: vehicle, ERI (0.7 mg/kg, IV, QW), PEGPH20 (37.5 µg/kg, IV, BIW), or ERI plus PEGPH20. In the parental HCC1806 model, addition of PEGPH20 did not significantly change the antitumor effects of ERI. In contrast, combining PEGPH20 with ERI in the HCC1806/HAS3 model increased the antitumor effects of ERI by 27% (94.5% vs. 119.7% TGI, ERI alone vs. ERI+PEGPH20, respectively; p=0.05) and resulted in 6 of 7 complete tumor regressions.

In a complementary study in HCC1806/HAS3 tumors evaluating ERI pharmacokinetics with and without PEGPH20, mice were assigned to three treatments groups: ERI (0.5 mg/kg, IV), simultaneous ERI plus PEGPH20 (37.5 µg/kg, IV); or ERI plus PEGPH20 predosed 24 h prior to ERI. Animals were sacrificed at 0.5, 1, 4, 24, 48, 72 and 96 h post ERI dose, and ERI levels in tumor, muscle, plasma and liver were subsequently analyzed by liquid/liquid extraction and LC-MS/MS chromatography. Simultaneous administration of ERI and PEGPH20 increased ERI maximum tumor concentration (Cmax) slightly and approximately doubled ERI tumor exposure (AUC); whereas the 24 h pretreatment with PEGPH20 approximately doubled ERI Cmax and increased ERI AUC more than two-fold. No significant differences in plasma ERI levels were observed between groups, and no significant differences in ERI levels in liver or muscle tissue were observed between groups. Taken together, these data suggest that PEGPH20-mediated HA removal significantly increases both ERI tumor concentrations and antitumor effectiveness in an HA-high TNBC model. A clinical phase 1b/2 clinical trial is planned to evaluate PEGPH20 plus ERI in first-line HER2-negative metastatic breast cancer.

Citation Format: Bahn JD, DesJardins C, Condon KB, Fathallah A, Zimmerman S, Maneval DC, Littlefield BA, Thompson CB. Pegylated recombinant human hyaluronidase PH20 (PEGPH20) enhances efficacy of eribulin mesylate (HALAVEN®) in triple negative breast cancer xenografts. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-03-09.

Differentiating neuromyelitis optica from other causes of longitudinally extensive transverse myelitis on spinal magnetic resonance imaging

BACKGROUND

Although spinal magnetic resonance imaging (MRI) findings of neuromyelitis optica (NMO) have been described, there is limited data available that help differentiate NMO from other causes of longitudinally extensive transverse myelitis (LETM).

OBJECTIVE

To investigate the spinal MRI findings of LETM that help differentiate NMO at the acute stage from multiple sclerosis (MS) and other causes of LETM.

METHODS

We enrolled 94 patients with LETM into our study. Bright spotty lesions (BSL), the lesion distribution and location were evaluated on axial T2-weighted images. Brainstem extension, cord expansion, T1 darkness and lesion enhancement were noted. We also reviewed the brain MRI of the patients during LETM.

RESULTS

Patients with NMO had a greater amount of BSL and T1 dark lesions (p < 0.001 and 0.003, respectively). The lesions in NMO patients were more likely to involve greater than one-half of the spinal cord's cross-sectional area; to enhance and be centrally-located, or both centrally- and peripherally-located in the cord. Of the 62 available brain MRIs, 14 of the 27 whom were NMO patients had findings that may be specific to NMO.

CONCLUSIONS

Certain spinal cord MRI features are more commonly seen in NMO patients and so obtaining brain MRI during LETM may support diagnosis.

Attitudinal Determinants of Local Public Health Workers' Participation in Hurricane Sandy Recovery Activities

Local health departments play a critical role in short-, intermediate-, and long-term recovery activities after a public health emergency. However, research has not explored attitudinal determinants of health department workers' participation in the recovery phase following a disaster. Accordingly, this qualitative investigation aims to understand perceived facilitators and barriers to performing recovery-related activities following Hurricane Sandy among local health department workers. In January 2014, 2 focus groups were conducted in geographically representative clusters of local health departments affected by Hurricane Sandy (1 cluster in Maryland and 1 cluster in New Jersey). Focus groups were recorded, transcribed verbatim, and analyzed to qualitatively assess attitudes toward Hurricane Sandy recovery activities. This analysis identified 5 major thematic categories as facilitators and barriers to participation in recovery activities: training, safety, family preparedness, policies and planning, and efficacy. Systems that support engagement of health department personnel in recovery activities may endeavor to develop and communicate intra- and interjurisdictional policies that minimize barriers in these areas. Development and implementation of evidence-informed curricular interventions that explain recovery roles may also increase local health department worker motivation to participate in recovery activities.

Efficacy of Glutamate Modulators in Tic Suppression: A Double-Blind, Randomized Control Trial of D-serine and Riluzole in Tourette Syndrome

BACKGROUND

It has been hypothesized that glutamatergic transmission may be altered in Tourette syndrome. In this study, we explored the efficacy of a glutamate agonist (D-serine) and antagonist (riluzole) as tic-suppressing agents in children with Tourette syndrome.

METHODS

We performed a parallel three-arm, 8-week, double-blind, randomized placebo-controlled treatment study in children with Tourette syndrome. Each child received 6 weeks of treatment with D-serine (maximum dose 30 mg/kg/day), riluzole (maximum dose 200 mg/day), or placebo, followed by a 2-week taper. The primary outcome measure was effective tic suppression as determined by the differences in the Yale Global Tic Severity Scale score; specifically, the total tic score and the combined score (total tic score + global impairment) between treatment arms after 6 weeks of treatment. Mann-Whitney U tests were performed to analyze differences between each group and the placebo group.

RESULTS

Twenty-four patients (males = 21, ages 9-18) enrolled in the study; one patient dropped out before completion. Combined Yale Global Tic Severity Scale score and total tic scores improved in all groups. The 6-week mean percent improvement of the riluzole (n = 10), D-serine (n = 9), and placebo (n = 5) groups in the combined Yale Global Tic Severity Scale score were 43.7, 39.5, and 30.2 and for total tic scores were 38.0, 25.0, and 34.0, respectively. There were no significant differences in Yale Global Tic Severity Scale score or total tic score, respectively, between the riluzole and placebo (P = 0.35, 0.85) or D-serine and placebo (P = 0.50, 0.69) groups.

CONCLUSION

Tics diminished by comparable percentages in the riluzole, D-serine, and placebo groups. These preliminary data suggest that D-serine and riluzole are not effective in tic suppression.

Infection Prevention Promotion Program Based on the PRECEDE Model: Improving Hand Hygiene Behaviors among Healthcare Personnel

Background.

Healthcare-associated infections (HAIs) result in significant morbidity and mortality. Hand hygiene remains a cornerstone intervention for preventing HAIs. Unfortunately, adherence to hand hygiene guidelines among healthcare personnel is poor.

Objective.

To assess short- and long-term effects of an infection prevention promotion program on healthcare personnel hand hygiene behaviors.

Design.

Time series design.

Setting

Our study was conducted at a tertiary care academic center.

Participants.

Hospital healthcare personnel.

Methods.

We developed a multimodal program that included a multimedia communications campaign, education, leadership engagement, environment modification, team performance measurement, and feedback. Healthcare personnel hand hygiene practices were measured via direct observations over a 3-year period by “undercover” observers.

Results.

Overall hand hygiene compliance increased by 2-fold after full program implementation (P<.001), and this increase was sustained over a 20-month follow-up period (P< .001). The odds for compliance with hand hygiene increased by 3.8-fold in the 6 months after full program implementation (95% confidence interval, 3.53–4.23; P< .001), and this increase was sustained. There was even a modest increase at 20 months of follow up. Hand hygiene compliance increased among all disciplines and hospital units. Hand hygiene compliance increased from 35% in the first 6 months after program initiation to 77% in the last 6 months of the study period among nursing providers (P<.001), from 38% to 62% among medical providers (P<.001), and from 27% to 75% among environmental services staff (P<.001).

Conclusions.

Implementation of the infection prevention promotion program was associated with a significant and sustained increase in hand hygiene practices among healthcare personnel of various disciplines.

Infect Control Hosp Epidemiol 2012;33(2):144-151

Local health department workers, public policy, and willingness to respond during emergencies

OBJECTIVES

To determine whether an association exists between a state's authority to declare a public health emergency and local public health workers' response willingness.

DESIGN

The 2009-2010 Johns Hopkins~Public Health Infrastructure Response Survey Tool included questions about demographics and attitudes/beliefs regarding local public health workers' response willingness during public health emergencies. Survey data were merged with data about presence/absence of a law granting states the authority to declare a public health emergency. Logistic regression analyses were performed with the presence/absence of the law and were adjusted for individuals' demographic and locale characteristics.

SETTING

Data were collected from eight clusters of local health department workers in nine states.

PARTICIPANTS

Two thousand nine hundred ninety-three local health department workers.

MAIN OUTCOME MEASURE

Willingness to respond to four different public health emergency scenarios.

RESULTS

For naturally occurring and human-caused disasters, in unadjusted analyses, there was no statistically significant difference in willingness to respond between individuals living in states with a law that allowed for a governmental declaration of public health emergency and those living in states without such a law. Adjusted analyses yielded similar results.

CONCLUSIONS

While laws giving the state the authority to declare a public health emergency are not associated with response willingness, findings may reflect the fact that states rarely declare public health emergencies, giving local public health workers few opportunities to become familiar with the implementation of these laws. In light of this, local health departments should consider altering their own internal policies to promote response willingness among their employees.

An academic-government-faith partnership to build disaster mental health preparedness and community resilience

OBJECTIVES

Faculty and affiliates of the Johns Hopkins Preparedness and Emergency Response Research Center partnered with local health departments and faith-based organizations to develop a dual-intervention model of capacity-building for public mental health preparedness and community resilience. Project objectives included (1) determining the feasibility of the tri-partite collaborative concept; (2) designing, delivering, and evaluating psychological first aid (PFA) training and guided preparedness planning (GPP); and (3) documenting preliminary evidence of the sustainability and impact of the model.

METHODS

We evaluated intervention effectiveness by analyzing pre- and post-training changes in participant responses on knowledge-acquisition tests administered to three urban and four rural community cohorts. Changes in percent of correct items and mean total correct items were evaluated. Criteria for model sustainability and impact were, respectively, observations of nonacademic partners engaging in efforts to advance post-project preparedness alliances, and project-attributable changes in preparedness-related practices of local or state governments.

RESULTS

The majority (11 of 14) test items addressing technical or practical PFA content showed significant improvement; we observed comparable testing results for GPP training. Government and faith partners developed ideas and tools for sustaining preparedness activities, and numerous project-driven changes in local and state government policies were documented.

CONCLUSIONS

Results suggest that the model could be an effective approach to promoting public health preparedness and community resilience.

Evaluation of prophylaxis treatment of Candida in alaryngeal patients with tracheoesophageal voice prostheses

OBJECTIVES/HYPOTHESIS

The objective of this study was to evaluate the effectiveness of nystatin and Biotène(®) mouthwash Oral Rinse for controlling Candida in total laryngectomy (TL) patients with a tracheosophageal voice prosthesis (TEP) because Biotène(®) mouthwash Oral Rinse is a less costly alternative to nystatin and requires less adherence time.

STUDY DESIGN

Randomized, unblinded, crossover trial.

METHODS

Twenty-one TL patients were randomized to receive nystatin followed by Biotène(®) mouthwash Oral Rinse, or the reverse order, after a basic oral-care phase (i.e., brushing teeth, cleaning dentures). A Provox(®) 2, 22.5 French TEP, which is an indwelling silicone voice prosthesis, was placed at the beginning of each phase. Patients were provided with oral care instructions at randomization and medication-specific instructions with each treatment's initiation. TEPs were processed and evaluated for Candida growth as colony-forming units (CFUs). Wilcoxon signed-rank tests were used for comparisons between treatments.

RESULTS

Fifteen patients were available for comparisons of Candida counts (6 received nystatin; 9 received Biotène(®) mouthwash first). Overall, the median log10 (CFUs) remained high regardless of treatment (no medication: 8.9; nystatin: 8.7; Biotène(®) mouthwash: 8.4). However, the median counts for both nystatin and Biotène(®) mouthwash Oral Rinse were lower than those for no medication (difference [Δ]:-0.9 and -0.3, respectively), although only nystatin was significantly lower (P = 0.02). There was no significant difference between the two treatments (P = 0.22). Overall, median medication-adherence was high (97%), and Biotène(®) mouthwash adherence was significantly higher than that of nystatin (Δ: 7.6%; P = 0.03).

CONCLUSION

Nystatin and Biotène(®) mouthwash Oral Rinse had similar CFU levels, with nystatin showing a significant improvement over usual oral care. Biotène(®) mouthwash is a less costly alternative to nystatin, with a less complex treatment protocol that might make it preferable to patients and clinicians.

LEVEL OF EVIDENCE

1b

Clinical and psychosocial risk factors of hearing outcome in older adults with cochlear implants

OBJECTIVES/HYPOTHESIS

To identify psychosocial determinants of speech perception (SP) outcome in older adults after cochlear implant (CI) surgery.

STUDY DESIGN

Retrospective study.

METHODS

Subjects received their CI at age 45 years or older and had at least 12 months of device experience. Independent variables consisted of the Charlson Comorbidity Index, history of depression, length of hearing loss and amplification use, residential status, education and gaps in SP data. Regression models were evaluated for associations with open-set SP gains at 3 months and 12 months, and in the 6- to 12-month time interval.

RESULTS

Every 10% increase in the proportion of life spent using a hearing aid was associated with a 2% to 3% decrement in SP gain within the first 3 months of CI use. Later and overall 1y SP gains were negatively impacted by poorer general health, lower education level, and residence in an assisted-living facility. Patients with gaps in SP data at later time points were also more likely to have poorer health and to live in assisted-living facilities. The absence of two or more evaluations was associated on average with 6.3% lower SP outcome compared to subjects with one or fewer missing data points. Age at CI had no influence on the size of post-operative SP gains.

CONCLUSIONS

Auditory deprivation and the influence of psychosocial and health factors on engagement in postsurgical rehabilitation services may impact CI outcomes more than has been previously reported. These findings have policy implications and highlight the need for more effective delivery of hearing rehabilitation services to an aging population.

Public health-specific personal disaster preparedness training: an academic-practice collaboration

OBJECTIVES

To measure the following three relevant outcomes of a personal preparedness curriculum for public health workers: 1) the extent of change (increase) in knowledge about personal preparedness activities and knowledge about tools for conducting personal preparedness activities; 2) the extent of change (increase) in preparedness activities performed post-training and/or confidence in conducting these tasks; and 3) an understanding of how to improve levels of personal preparedness using the Extended Parallel Process Model (EPPM) framework.

DESIGN

Cross-sectional preinterventional and postinterventional survey using a convenience sample.

SETTING

During 2010, three face-to-face workshops were conducted in three locations in West Virginia.

PARTICIPANTS

One hundred thirty-one participants (baseline survey); 69 participants (1-year resurvey)-representing West Virginia local health department (LHD) and State Health Department employees.

INTERVENTIONS

A 3-hour interactive, public health-specific, face-to-face workshop on personal disaster preparedness.

MAIN OUTCOME MEASURE(S)

Change in 1) knowledge about, and tools for, personal preparedness activities; 2) preparedness activities performed post-training and/or confidence in conducting these activities; and 3) the relationship of EPPM categories to personal preparedness activities.

RESULTS

One year postworkshop, 77 percent of respondents reported having personal emergency kits (40 percent at baseline) and 67 percent reported having preparedness plans (38 percent at baseline) suggesting some participants assembled supply kits and plans postworkshop. Within the context of EPPM, respondents in high-threat categories agreed more often than respondents in low-threat categories that severe personal impacts were likely to result from a moderate flood. Compared to respondents categorized as low efficacy, respondents in high-efficacy categories perceived confidence in their knowledge and an impact of their response on their job success at higher rates.

CONCLUSIONS

Personal disaster preparedness trainings for the LHD workforce can yield gains in relevant preparedness behaviors and attitudes but may require longitudinal reinforcement. The EPPM can offer a useful threat and efficacy-based lens to understand relevant perceptions surrounding personal disaster preparedness behaviors among LHD employees.

EPPM and willingness to respond: the role of risk and efficacy communication in strengthening public health emergency response systems

This study examines the attitudinal impact of an Extended Parallel Process Model (EPPM)-based training curriculum on local public health department (LHD) workers' willingness to respond to representative public health emergency scenarios. Data are from 71 U.S. LHDs in urban and rural settings across nine states. The study explores changes in response willingness and EPPM threat and efficacy appraisals between randomly assigned control versus intervention health departments, at baseline and 1 week post curriculum, through an EPPM-based survey/resurvey design. Levels of response willingness and emergency response-related attitudes/beliefs are measured. Analyses focus on two scenario categories that have appeared on a U.S. government list of scenarios of significant concern: a weather-related emergency and a radiological "dirty" bomb event (U.S. Department of Homeland Security, 2007). The greatest impact from the training intervention on response willingness was observed among LHD workers who had low levels of EPPM-related threat and efficacy perceptions at baseline. Self-efficacy and response efficacy and response willingness increased in intervention LHDs for both scenarios, with greater response willingness increases observed for the radiological "dirty" bomb terrorism scenario. Findings indicate the importance of building efficacy versus enhancing threat perceptions as a path toward greater response willingness, and suggest the potential applicability of such curricular interventions for boosting emergency response willingness among other cadres of health providers.

An intervention for enhancing public health crisis response willingness among local health department workers: a qualitative programmatic analysis

OBJECTIVES

This study evaluated the impact of a novel multimethod curricular intervention using a train-the-trainer model: the Public Health Infrastructure Training (PHIT). PHIT was designed to 1) modify perceptions of self-efficacy, response efficacy, and threat related to specific hazards and 2) improve the willingness of local health department (LHD) workers to report to duty when called upon.

METHODS

Between June 2009 and October 2010, eight clusters of US LHDs (n = 49) received PHIT. Two rounds of focus groups at each intervention site were used to evaluate PHIT. The first round of focus groups included separate sessions for trainers and trainees, 3 weeks after PHIT. The second round of focus groups combined trainers and trainees in a single group at each site 6 months following PHIT. During the second focus group round, participants were asked to self-assess their preparedness before and after PHIT implementation.

SETTING

Focus groups were conducted at eight geographically representative clusters of LHDs.

PARTICIPANTS

Focus group participants included PHIT trainers and PHIT trainees within each LHD cluster.

MAIN OUTCOME MEASURE(S)

Focus groups were used to assess attitudes toward the curricular intervention and modifications of willingness to respond (WTR) to an emergency; self-efficacy; and response efficacy.

RESULTS

Participants reported that despite challenges in administering the training, PHIT was well designed and appropriate for multiple management levels and disciplines. Positive mean changes were observed for all nine self-rated preparedness factors (p < 0.001). The findings show PHIT's benefit in improving self-efficacy and WTR among participants.

CONCLUSIONS

The PHIT has the potential to enhance emergency response willingness and related self-efficacy among LHD workers.

The Public Health Workforce and Willingness to Respond to Emergencies: A 50-State Analysis of Potentially Influential Laws

Law plays a critical role in all stages of a public health emergency, providing an infrastructure for planning, response, and recovery efforts. A growing body of research has underscored the potential for certain types of state laws, such as those granting liability protections to responders, to influence the public health workforce's participation in emergency responses. It is therefore especially important to focus on particular state-level laws that may be associated with individuals' increased or decreased willingness to respond. We conducted a systematic identification and analysis of specific state emergency preparedness laws that may affect individuals' willingness to respond and offer recommendations for policymakers seeking to promote more effective responses to public health emergencies.

Survival after diagnosis of localized T1a kidney cancer: current population-based practice of surgery and nonsurgical management

OBJECTIVE

To compare overall and cancer-specific survival (CSS) of patients who undergo nonsurgical management (NSM), partial nephrectomy (PN), and radical nephrectomy (RN). NSM is being increasingly used for older patients with early-stage kidney cancer and competing risks of death. However, survival is poorly characterized for this approach compared with surgery with PN or RN.

METHODS

The Surveillance, Epidemiology and End Results-Medicare database from 1995 to 2007 was used to identify patients aged 65 years or older diagnosed with localized T1a kidney cancer treated with PN, RN, or NSM. We used Cox proportional hazards regression, Fine and Gray competing risks regression, and propensity score matching to adjust for patient and tumor characteristics.

RESULTS

Of 7177 Medicare beneficiaries meeting the inclusion criteria, 754 (10.5%) underwent NSM, 1849 (25.8%) PN, and 4574 (63.7%) RN, with 436 (57.8%), 389 (21.0%), and 1598 (34.9%) patients dying from any cause, respectively, at a median follow-up of 56 months. Overall survival favored PN and RN compared with NSM (hazard ratio [95% CI]: 0.40 [0.34-0.46] and 0.50 [0.45-0.56], respectively) as did CSS (hazard ratio [95% CI]: 0.42 [0.27-0.64] and 0.62 [0.46-0.85], respectively). However, there was no difference in CSS between any 2 treatment groups for younger patients (<75 years), whereas there was an excess of kidney cancer deaths for NSM patients aged 75-79 years and an attenuated difference for patients aged 80 years or older.

CONCLUSION

NSM was associated with an increased risk of kidney cancer death among Medicare beneficiaries aged 75-79 years. Evolving active surveillance protocols will need to develop robust selection criteria to maximize cancer survival for older patients with kidney cancer.

Reducing radiation dose while maintaining diagnostic image quality of cerebral three-dimensional digital subtraction angiography: an in vivo study in swine

BACKGROUND

Three-dimensional digital subtraction angiography (3D-DSA) is a modern technique that allows for better appreciation of complex vascular lesions. This study evaluates the impact of various dose reduction strategies on 3D-DSA image quality.

METHODS

The standard manufacturer 5 s 0.36 μGy/frame setting was modified to create lower dose 3D-DSA protocols by varying the acquisition time (5 or 3 s) and/or dose per frame (0.36, 0.24, 0.17, and 0.10 μGy/f). All protocols were evaluated in three swine. Four raters measured a segment of the external carotid artery on two-dimensional multiplanar reconstruction images. The raters were also presented with three-dimensional volume rendered images from all protocols in a blinded manner and asked to choose the superior image. A full model analysis of variance with repeated measure factors was performed to compare mean differences in measurements between protocols.

RESULTS

Measurement differences between the standard and low dose protocols were not clinically significant (<0.5 mm). All raters demonstrated high inter-rater reliability. The 5 s protocols were considered as qualitatively superior to the 3 s protocols. Delivered system doses ranged from 43.8 to 6.5 mGy. The 5 s 0.10 μGy/frame protocols generated 65-68% less delivered dose compared with the 5 s 0.36 μGy/frame setting.

CONCLUSIONS

Low dose 3D-DSA protocols with preserved image quality are achievable, and can help reduce unnecessary radiation exposure to both patients and operators. The 5 s low dose protocols generated clinically acceptable and superior images compared with the 3 s protocols, suggesting a more important role for acquisition time than dose per frame to maintain image quality.

Impact of a home-based walking intervention on outcomes of sleep quality, emotional distress, and fatigue in patients undergoing treatment for solid tumors

Exercise use among patients with cancer has been shown to have many benefits and few notable risks. The purpose of this study was to evaluate the impact of a home-based walking intervention during cancer treatment on sleep quality, emotional distress, and fatigue. Methods. A total of 138 patients with prostate (55.6%), breast (32.5%), and other solid tumors (11.9%) were randomized to a home-based walking intervention or usual care. Exercise dose was assessed using a five-item subscale of the Cooper Aerobics Center Longitudinal Study Physical Activity Questionnaire. Primary outcomes of sleep quality, distress, and fatigue were compared between the two study arms. Results. The exercise group (n = 68) reported more vigor (p = .03) than control group participants (n = 58). In dose response models, greater participation in aerobic exercise was associated with 11% less fatigue (p < .001), 7.5% more vigor (p = .001), and 3% less emotional distress (p = .03), after controlling for intervention group assignment, age, and baseline exercise and fatigue levels. Conclusion. Patients who exercised during cancer treatment experienced less emotional distress than those who were less active. Increasing exercise was also associated with less fatigue and more vigor. Home-based walking is a simple, sustainable strategy that may be helpful in improving a number of symptoms encountered by patients undergoing active treatment for cancer.

Assessment of medical reserve corps volunteers' emergency response willingness using a threat- and efficacy-based model

The goal of this study was to investigate the willingness of Medical Reserve Corps (MRC) volunteers to participate in public health emergency-related activities by assessing their attitudes and beliefs. MRC volunteers responded to an online survey organized around the Extended Parallel Process Model (EPPM). Respondents reported agreement with attitude/belief statements representing perceived threat, perceived efficacy, and personal/organizational preparedness in 4 scenarios: a weather-related disaster, a pandemic influenza emergency, a radiological ("dirty bomb") emergency, and an inhalational anthrax bioterrorism emergency. Logistic regression analyses were used to evaluate predictors of volunteer response willingness. In 2 response contexts (if asked and regardless of severity), self-reported willingness to respond was higher among those with a high perceived self-efficacy than among those with low perceived self-efficacy. Analyses of the association between attitude/belief statements and the EPPM profiles indicated that, under all 4 scenarios and with few exceptions, those with a perceived high threat/high efficacy EPPM profile had statistically higher odds of agreement with the attitude/belief statements than those with a perceived low threat/low efficacy EPPM profile. The radiological emergency consistently received the lowest agreement rates for the attitude/belief statements and response willingness across scenarios. The findings suggest that enrollment with an MRC unit is not automatically predictive of willingness to respond in these types of scenarios. While MRC volunteers' self-reported willingness to respond was found to differ across scenarios and among different attitude and belief statements, the identification of self-efficacy as the primary predictor of willingness to respond regardless of severity and if asked highlights the critical role of efficacy in an organized volunteer response context.

Epidemiology, outcomes, and mortality predictors of invasive mold infections among transplant recipients: a 10-year, single-center experience

BACKGROUND

The epidemiology of invasive mold infections (IMI) in transplant recipients differs based on geography, hosts, preventative strategies, and methods of diagnosis.

METHODS

We conducted a retrospective observational study to evaluate the epidemiology of proven and probable IMI, using prior definitions, among all adult hematopoietic stem cell transplant (HSCT) and solid organ transplant (SOT) recipients in the era of "classic" culture-based diagnostics (2000-2009). Epidemiology was evaluated before and after an initiative was begun to increase bronchoscopy in HSCT recipients after 2005.

RESULTS

In total, 106 patients with one IMI were identified. Invasive aspergillosis (IA) was the most common IMI (69; 65.1%), followed by mucormycosis (9; 8.5%). The overall rate of IMI (and IA) was 3.5% (2.5%) in allogeneic HSCT recipients. The overall incidence for IMI among lung, kidney, liver, and heart transplant recipients was 49, 2, 11, and 10 per 1000 person-years, respectively. The observed rate of IMI among human leukocyte antigen-matched unrelated and haploidentical HSCT recipients increased from 0.6% annually to 3.0% after bronchoscopy initiation (P < 0.05). The 12-week mortality among allogeneic HSCT, liver, kidney, heart, and lung recipients with IMI was 52.4%, 47.1%, 27.8%, 16.7%, and 9.5%, respectively. Among allogeneic HSCT (odds ratio [OR]: 0.07, P = 0.007) and SOT (OR: 0.22, P = 0.05) recipients with IA, normal platelet count was associated with improved survival. Male gender (OR: 14.4, P = 0.007) and elevated bilirubin (OR: 5.7, P = 0.04) were significant predictors of mortality for allogeneic HSCT and SOT recipients with IA, respectively.

CONCLUSIONS

During the era of culture-based diagnostics, observed rates of IMI were low among all transplants except lung transplant recipients, with relatively higher mortality rates. Diagnostic aggressiveness and host variables impact the reported incidence and outcome of IMI and likely account for institutional variability in multicenter studies. Definitions to standardize diagnoses among SOT recipients are needed.

Characterizing public health emergency perceptions and influential modifiers of willingness to respond among pediatric healthcare staff

OBJECTIVES

The aim of this study was to characterize the public health emergency perceptions and willingness to respond (WTR) of hospital-based pediatric staff and to use these findings to propose a methodology for developing an institution-specific training package to improve response willingness.

METHODS

A prospective anonymous web-based survey was conducted at the Johns Hopkins Hospital, including the 180-bed Johns Hopkins Children's Center, between January and March 2009. In this survey, participants' attitudes/beliefs regarding emergency response to a pandemic influenza and a radiological dispersal device (RDD or "dirty bomb") event were assessed.

RESULTS

Of the 1,620 eligible pediatric staff 246 replies (15.2 percent response rate) were received, compared with an overall staff response rate of 18.4 percent. Characteristics of respondent demographics and professions were similar to those of overall hospital staff. Self-reported WTR was greater for a pandemic influenza than for an RDD event if required (84.6 percent vs 75.1 percent), and if asked, but not required (74.4 percent vs 64.5 percent). The majority of pediatric staff were not confident in their safety at work (pandemic influenza: 51.8 percent and RDD: 76.6 percent), were far less likely to respond if personal protective equipment was unavailable (pandemic influenza: 33.5 percent and RDD: 21.6percent), and wanted furtherpre-event preparation and training (pandemic influenza: 89.6 percent and RDD: 82.6 percent). The following six distinct perceived attitudes / beliefs were identified as having institution-specific high impact on response willingness: colleague response, skill mastery, safety getting to work, safety at work, ability to perform duties, and individual response efficacy.

CONCLUSIONS

Children represent a uniquely vulnerable population in public health emergencies, and pediatric hospital staff accordingly represent a vital subset of responders distinguished by specialized education, training, clinical skills, and disaster competencies. Even though the majority of pediatric hospital staff report WTR, nearly 15 percent for a pandemic influenza emergency and 25 percent for an RDD event would not respond if required. Other institutions can apply the methodology used here to identify particularly influential response willingness modifiers for pediatric care providers. These insights can inform customized preparedness training for pediatric healthcare workers, through identification of high-impact attitudes/beliefs, and training initiatives focused on addressing these modifiers.

Pain prevalence, intensity, assessment and management in a hospitalized pediatric population

New research, regulatory guidelines, and practice initiatives have improved pain management in infants, children, and adolescents, but obstacles remain. The aim of this study was to identify the prevalence and demographics of pain, as well as pain management practice patterns in hospitalized children in a tertiary-care university hospital. We prospectively collected data including patient demographics, presence/absence and location of pain, pain intensity, pain assessment documentation, analgesic use, side effects of analgesic therapy, and patient/family satisfaction. Two hundred male (58%) and female, medical and surgical (61%) patients, averaging 9 ± 6.2 years were studied. Pain was common (86%) and often moderate to severe (40%). Surgical patients reported pain more frequently when enrolled than did medical patients (99% vs. 65%). Female gender, age ≥ 5 years, and Caucasian race were all associated with higher mean pain scores. Furthermore, females and Caucasian children consumed more opioids than males and non-Caucasians. Identified obstacles to optimal analgesic management include lack of documented physician pain assessment (<5%), a high prevalence of "as needed" analgesic dosing, frequent opioid-induced side effects (44% nausea and vomiting, 27% pruritus), and patient/family dissatisfaction with pain management (2%-7%). The data demonstrated that despite a concentrated focus on improving pain management over the past decade, pain remains common in hospitalized children. Identification of patient populations and characteristics that predispose to increased pain (e.g., female, Caucasian, postoperative patient) as well as obstacles to analgesic management provide a focus for the development of targeted interventions and research to further improve care.

Rethinking the regulation of cellular metabolism

Most biologists working today have not considered the problem of how signal transduction events, which commit cells to energetically demanding processes such as growth and division, are connected to cellular metabolism. The primary reason for this is that we have believed for the last 30 or more years that the metabolism of cells is a homeostatic, self-regulating process that does not depend on any extracellular input. The traditional view is that a mammalian cell decides to take up nutrients whenever its bioenergetic and synthetic reserves are depleted. However, a considerable body of evidence now exists that challenges the notion that the nutrient uptake and metabolism of metazoan cells are cell-autonomous.

Determinants of emergency response willingness in the local public health workforce by jurisdictional and scenario patterns: a cross-sectional survey

Background

The all-hazards willingness to respond (WTR) of local public health personnel is critical to emergency preparedness. This study applied a threat-and efficacy-centered framework to characterize these workers' scenario and jurisdictional response willingness patterns toward a range of naturally-occurring and terrorism-related emergency scenarios.

Methods

Eight geographically diverse local health department (LHD) clusters (four urban and four rural) across the U.S. were recruited and administered an online survey about response willingness and related attitudes/beliefs toward four different public health emergency scenarios between April 2009 and June 2010 (66% response rate). Responses were dichotomized and analyzed using generalized linear multilevel mixed model analyses that also account for within-cluster and within-LHD correlations.

Results

Comparisons of rural to urban LHD workers showed statistically significant odds ratios (ORs) for WTR context across scenarios ranging from 1.5 to 2.4. When employees over 40 years old were compared to their younger counterparts, the ORs of WTR ranged from 1.27 to 1.58, and when females were compared to males, the ORs of WTR ranged from 0.57 to 0.61. Across the eight clusters, the percentage of workers indicating they would be unwilling to respond regardless of severity ranged from 14-28% for a weather event; 9-27% for pandemic influenza; 30-56% for a radiological 'dirty' bomb event; and 22-48% for an inhalational anthrax bioterrorism event. Efficacy was consistently identified as an important independent predictor of WTR.

Conclusions

Response willingness deficits in the local public health workforce pose a threat to all-hazards response capacity and health security. Local public health agencies and their stakeholders may incorporate key findings, including identified scenario-based willingness gaps and the importance of efficacy, as targets of preparedness curriculum development efforts and policies for enhancing response willingness. Reasons for an increased willingness in rural cohorts compared to urban cohorts should be further investigated in order to understand and develop methods for improving their overall response.

Factors affecting clot lysis rates in patients with spontaneous intraventricular hemorrhage

BACKGROUND AND PURPOSE

In the treatment of severe intraventricular hemorrhage (IVH), thrombolytic use and clot size are known to influence clot lysis rates. We evaluated the effect of other variables on IVH clot lysis rates among patients treated with recombinant tissue-type plasminogen activator or placebo.

METHODS

One hundred patients with IVH and intracerebral hemorrhage volume <30 mL requiring emergency external ventricular drainage from 2 multicenter trials were treated with intraventricular administration of recombinant tissue-type plasminogen activator (n=78; 53 males, 25 females) or placebo (n=22; 7 males, 15 females). IVH volume was quantified daily by head CT. A segmented linear regression using an optimized spline knot for each patient was fit. Random effects linear regression was used to estimate the effect of prespecified patient characteristics on clot lysis rates over the first 6 days.

RESULTS

Stability IVH volumes were larger in males (N=60; 54 ± 5 mL) than females (N=40; 36 ± 5 mL; P=0.01). Intraventricular thrombolytic treatment was associated with an increase in clot lysis rate of 14.6% of stability IVH volume/day before the spline knot compared with the placebo group (P<0.001). After adjustment for thrombolytic, higher baseline serum plasminogen and lower baseline platelet count were independently associated with an increase in clot lysis of 1.28%/day per 10-g/dL increase (P<0.001) and 0.70% /day per 10×10(3)/uL decrease (P<0.001) before the knot, respectively.

CONCLUSIONS

Although thrombolysis remains the major determinant of IVH clot lysis rate, higher baseline serum plasminogen and lower platelet count also predict faster clot lysis. Further studies are needed to confirm whether plasminogen availability and thrombus structure impact IVH clot removal. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00650858.

Administration of voriconazole in patients with renal dysfunction

BACKGROUND

The intravenous use of voriconazole requires coadministration with sulphobutylether-β-cyclodextrin, which may accumulate in patients with impaired renal function.

METHODS

All adult patients treated with the same formulation of voriconazole for a minimum of 3 consecutive days were included. Renal function was assessed based on the creatinine level and the calculated creatinine clearance (CrCl). Change in renal function was calculated on days 3, 7, and end of treatment (EOT) and was defined based on the RIFLE criteria.

RESULTS

Among 166 patients in whom baseline renal function was assessed, 42 (25.3%) had a CrCl <50 mL/min and received intravenous voriconazole, 77 (46.4%) had a CrCl ≥50 mL/min and received intravenous voriconazole, and 47 (28.3%) had a CrCl <50 mL/min and were treated with oral voriconazole. Renal function changed on days 3, 7, and EOT in 19 (11.4%), 14 (8.4%), and 28 (16.9%) patients, respectively. Multivariate analyses identified significant predictors of renal dysfunction: (1) day 3, hematologic malignancy (odds ratio [OR], 5.09, P = .01), fluconazole use within 30 days prior to voriconazole (OR, 6.21; P = .008), coadministration of penicillins (OR, 6.12; P = .03), and immunosuppressants (OR, 7.00; P = .002); (2) day 7, baseline liver impairment (OR, 5.30; P value = .004); (3) EOT, administration of penicillins (OR, 2.39; P = .04).

CONCLUSIONS

Voriconazole route of administration and baseline renal function were not predictors of worsening renal dysfunction on days 3, 7, and EOT. Underlying disease, baseline liver impairment, and concomitant administration of other drugs (eg, penicillins, fluoroquinolones, immunosuppressants) were the strongest predictors of renal dysfunction.

Assessment of psychological preparedness and emergency response willingness of local public health department and hospital workers

This study sought to investigate the relationship between psychologically-related attitudes/beliefs toward public health emergency response among local health department (LHD) and hospital workers and their willingness to respond to a pandemic influenza emergency scenario and a radiological 'dirty' bomb scenario, to inform workforce resilience-building interventions. LHD and hospital workers participated in a survey based on an established threat- and efficacy-oriented behavioral model (the extended parallel process model) that focused on collection of the aforementioned attitudes, beliefs, and self-reported response willingness. Odds ratios associating psychologically-related attitudes and beliefs with self-reported response willingness were computed Perceived levels of psychological preparedness and support were shown to impact response willingness, with more pronounced effects in the radiological 'dirty' bomb scenario. Compared to those who did not perceive themselves to be psychologically prepared, those who did perceive themselves as prepared had higher odds of self-reported response willingness. The relationship of these perceptions and self-reported willingness to respond in all contexts, both scenarios, and both cohorts was influenced by perceived self-efficacy andperceived family preparedness.