Nemabiome metabarcoding shows a high prevalence of Haemonchus contortus and predominance of Camelostrongylus mentulatus in alpaca herds in the northern UK

Gastrointestinal nematodes (GINs) are a common threat faced by pastoral livestock. Since their major introduction to the UK in the early 1990s, South American camelids have been cograzed with sheep, horses, and other livestock, allowing exposure to a range of GIN species. However, there have been no molecular-based studies to investigate the GIN populations present in these camelids. In the current study, we sampled nine alpaca herds from northern England and southern Scotland and used high-throughput metabarcoded sequencing to describe their GIN species composition. A total of 71 amplicon sequence variants (ASVs) were identified representing eight known GIN species. Haemonchus contortus was the most prevalent species found in almost all herds in significant proportions. The identification of H. contortus in other livestock species is unusual in the northern UK, implying that alpacas may be suitable hosts and potential reservoirs for infection in other hosts. In addition, the camelid-adapted GIN species Camelostrongylus mentulatus was identified predominantly in herds with higher faecal egg counts. These findings highlight the value of applying advanced molecular methods, such as nemabiome metabarcoding to describe the dynamics of gastrointestinal nematode infections in novel situations. The results provide a strong base for further studies involving cograzing animals to confirm the potential role of alpacas in transmitting GIN species between hosts.

Pannexin 1 dysregulation in Duchenne muscular dystrophy and its exacerbation of dystrophic features in mdx mice

BACKGROUND

Duchenne muscular dystrophy (DMD) is associated with impaired muscle regeneration, progressive muscle weakness, damage, and wasting. While the cause of DMD is an X-linked loss of function mutation in the gene encoding dystrophin, the exact mechanisms that perpetuate the disease progression are unknown. Our laboratory has demonstrated that pannexin 1 (Panx1 in rodents; PANX1 in humans) is critical for the development, strength, and regeneration of male skeletal muscle. In normal skeletal muscle, Panx1 is part of a multiprotein complex with dystrophin. We and others have previously shown that Panx1 levels and channel activity are dysregulated in various mouse models of DMD.

METHODS

We utilized myoblast cell lines derived from DMD patients to assess PANX1 expression and function. To investigate how Panx1 dysregulation contributes to DMD, we generated a dystrophic (mdx) mouse model that lacks Panx1 (Panx1-/-/mdx). In depth characterization of this model included histological analysis, as well as locomotor, and physiological tests such as muscle force and grip strength assessments.

RESULTS

Here, we demonstrate that PANX1 levels and channel function are reduced in patient-derived DMD myoblast cell lines. Panx1-/-/mdx mice have a significantly reduced lifespan, and decreased body weight due to lean mass loss. Their tibialis anterior were more affected than their soleus muscles and displayed reduced mass, myofiber loss, increased centrally nucleated myofibers, and a lower number of muscle stem cells compared to that of Panx1+/+/mdx mice. These detrimental effects were associated with muscle and locomotor functional impairments. In vitro, PANX1 overexpression in patient-derived DMD myoblasts improved their differentiation and fusion.

CONCLUSIONS

Collectively, our findings suggest that PANX1/Panx1 dysregulation in DMD exacerbates several aspects of the disease. Moreover, our results suggest a potential therapeutic benefit to increasing PANX1 levels in dystrophic muscles.

Association of Traumatic Brain Injury and Glioblastoma Multiforme: A Case Series

Glioblastoma multiforme (GBM) is an aggressive variant of central nervous system gliomas that carries a dismal prognosis. Although GBM is the most frequently occurring and malignant type of glioma accounting for more than 60% of all brain tumors in adults, its overall incidence is rare, occurring at a rate of 3.21 per 100,000 persons. Little is known about the etiology of GBM, but one proposed theory is that GBM pathogenesis may be linked to a chronic inflammatory course initiated by traumatic injury to the brain. Limited case reports have suggested an association between GBMs and traumatic brain injury (TBI), but larger case-control and epidemiologic studies have been inconclusive. We present three service members (two active duty and one retired) who developed GBM near the original site of prior head trauma. Each service member's military occupation was in the special operations community and shared a common theme of TBI following head trauma/injury. The current research on the association between TBI and GBM is limited and conflicting, predominantly due to the low incidence of the disease in the general population. Evidence has indicated that TBI should be considered a chronic disease with long-term health impacts, including long-term disability, dementia, epilepsy, mental health conditions, and cardiovascular diseases. With the addition of our patients, as well as a recently published study proposing a molecular association between trauma and GBM, further research is needed to better understand the potential relationship.

Comparison of interpersonal quality of contraceptive counseling delivered via telehealth versus in person

OBJECTIVES

This study aimed to compare the interpersonal quality of contraceptive counseling between telehealth and in-person visits.

STUDY DESIGN

Patients at a single Title X-funded clinic selected their preferred counseling modality (in person or telehealth via video or telephone) when scheduling an appointment for contraception. After counseling, we invited patients to complete a survey and recorded their desired contraceptive method. We assessed the quality of counseling using the Interpersonal Quality in Family Planning scale. We reviewed the electronic medical record to identify any subsequent clinician visit. We performed between-group comparisons using Mann-Whitney U, χ2, and Fisher exact tests.

RESULTS

From March 2021 to June 2022, 360 patients were eligible to participate, and 296 (82%) completed the survey and were included in the analysis; 150 (51%) completed counseling in person, and 146 (49%) completed counseling via telehealth. In the telehealth group, 102 (70%) chose telephone, and 44 (30%) chose video. Respondent characteristics were similar between groups. The majority of respondents in both groups reported high quality of counseling, defined as a top score on the Interpersonal Quality in Family Planning scale (75.0% telehealth respondents and 80.0% in person, p = 0.30). Compared to respondents completing in-person counseling, telehealth respondents were less likely to have a subsequent clinician visit (89.0% versus 100.0%, p < 0.001).

CONCLUSIONS

The majority of respondents reported high-quality contraceptive counseling without significant difference between the modalities. However, respondents choosing telehealth were less likely to have a subsequent clinician visit. Given the higher uptake of telephone compared to video, telehealth via telephone may be more accessible or acceptable to some patients.

IMPLICATIONS

Contraceptive counseling via telehealth has similar high interpersonal quality when compared to traditional, in-person visits. However, barriers may exist for patients who choose telehealth contraceptive counseling to access subsequent in-person care. Utilization of telehealth for contraceptive visits may provide opportunities for more equitable health care and to expand contraceptive access.

Inhibition of PANX1 Channels Reduces the Malignant Properties of Human High-Risk Neuroblastoma

Pannexin 1 (PANX1) is expressed in many tissue types including tissues of neural origin. Neuroblastoma (NB) is a neural crest-derived malignancy mainly occurring in children. The majority of NB patients present with high-risk disease for which current therapies are ineffective. Here, we show that while PANX1 is expressed in NB of all stages, high PANX1 expression in high-risk NB is associated with a reduced survival probability. PANX1 channel inhibition using probenecid (PBN) or carbenoxolone (CBX) reduced the proliferation of our panel of high-risk NB cell lines. We show that expression of the Y10F PANX1 mutant, which cannot be phosphorylated on tyrosine 10 and acts in a dominant-negative manner, curtailed NB cell proliferation. Furthermore, PBN and CBX treatment halted the growth of NB spheroids and in some cases triggered the regression of established NB spheroids. Finally, both drugs reduced the progression of high-risk NB in vivo. Together our data indicate that PANX1 channels regulate human NB malignant properties and that the use of PBN or CBX may provide a new therapeutic approach for high-risk NB.

The effects of systemic immunomodulatory treatments on COVID-19 outcomes in patients with atopic dermatitis: Results from the global SECURE-AD registry

BACKGROUND

Limited data are available on the effects of systemic immunomodulatory treatments on COVID-19 outcomes in patients with atopic dermatitis (AD).

OBJECTIVE

To investigate COVID-19 outcomes in patients with AD treated with or without systemic immunomodulatory treatments, using a global registry platform.

METHODS

Clinicians were encouraged to report cases of COVID-19 in their patients with AD in the Surveillance Epidemiology of Coronavirus Under Research Exclusion for Atopic Dermatitis (SECURE-AD) registry. Data entered from 1 April 2020 to 31 October 2021 were analysed using multivariable logistic regression. The primary outcome was hospitalization from COVID-19, according to AD treatment groups.

RESULTS

442 AD patients (mean age 35.9 years, 51.8% male) from 27 countries with strongly suspected or confirmed COVID-19 were included in analyses. 428 (96.8%) patients were treated with a single systemic therapy (n = 297 [67.2%]) or topical therapy only (n = 131 [29.6%]). Most patients treated with systemic therapies received dupilumab (n = 216). Fourteen patients (3.2%) received a combination of systemic therapies. Twenty-six patients (5.9%) were hospitalized. No deaths were reported. Patients treated with topical treatments had significantly higher odds of hospitalization, compared with those treated with dupilumab monotherapy (odds ratio (OR) 4.65 [95%CI 1.71-14.78]), including after adjustment for confounding variables (adjusted OR (aOR) 4.99 [95%CI 1.4-20.84]). Combination systemic therapy which did not include systemic corticosteroids was associated with increased odds of hospitalization, compared with single agent non-steroidal immunosuppressive systemic treatment (OR 8.09 [95%CI 0.4-59.96], aOR 37.57 [95%CI 1.05-871.11]). Hospitalization was most likely in patients treated with combination systemic therapy which included systemic corticosteroids (OR 40.43 [95%CI 8.16-207.49], aOR 45.75 [95%CI 4.54-616.22]).

CONCLUSIONS

Overall, the risk of COVID-19 complications appears low in patients with AD, even when treated with systemic immunomodulatory agents. Dupilumab monotherapy was associated with lower hospitalization than other therapies. Combination systemic treatment, particularly combinations including systemic corticosteroids, was associated with the highest risk of severe COVID-19.

Sex-dependent role of Pannexin 1 in regulating skeletal muscle and satellite cell function

The development and regeneration of skeletal muscle are mediated by satellite cells (SCs), which ensure the efficient formation of myofibers while repopulating the niche that allows muscle repair following injuries. Pannexin 1 (Panx1) channels are expressed in SCs and their levels increase during differentiation in vitro, as well as during skeletal muscle development and regeneration in vivo. Panx1 has recently been shown to regulate muscle regeneration by promoting bleb-based myoblast migration and fusion. While skeletal muscle is largely influenced in a sex-specific way, the sex-dependent roles of Panx1 in regulating skeletal muscle and SC function remain to be investigated. Here, using global Panx1 knockout (KO) mice, we demonstrate that Panx1 loss reduces muscle fiber size and strength, decreases SC number, and alters early SC differentiation and myoblast fusion in male, but not in female mice. Interestingly, while both male and female Panx1 KO mice display an increase in the number of regenerating fibers following acute injury, the newly formed fibers in male Panx1 KO mice are smaller. Overall, our results demonstrate that Panx1 plays a significant role in regulating muscle development, regeneration, and SC number and function in male mice and reveal distinct sex-dependent functions of Panx1 in skeletal muscle.

A Cross-Sectional, Population-Based, Seroepidemiological Study of Rift Valley Fever in Cameroonian Cattle Populations

Rift Valley fever (RVF) is an important emerging zoonoses causing abortion and neonatal deaths in livestock and hemorrhagic fever in humans. It is typically characterized by acute epidemics with abortion storms often preceding human disease and these events have been associated with the El Niño weather cycles. Outside of areas that experience epidemics, little is known about its epidemiology. Here, we present results from a serological study using biobank samples from a study of cattle conducted in 2013 at two sites in Cameroon. A total of 1,458 cattle from 100 herds were bled and sera screened using a commercially available RVF ELISA. The overall design-adjusted animal-level apparent seroprevalence of RVF exposure for the Northwest Region (NWR) of Cameroon was 6.5% (95% CI: 3.9–11.0) and for the Vina Division (VIN) of the Adamawa Region was 8.2% (95% CI: 6.2–11.0). The age-stratified serological results were also used to estimate the force of infection, and the age-independent estimates were 0.029 for the VIN and 0.024 for the NWR. The effective reproductive number was ~1.08. Increasing age and contact with wild antelope species were associated with an increased risk of seropositivity, while high altitudes and contact with buffalo were associated with a reduced risk of seropositivity. The serological patterns are more consistent with an endemical stability rather than the more typical epidemic patterns seen in East Africa. However, there is little surveillance in livestock for abortion storms or in humans with fevers in Cameroon, and it is, therefore, difficult to interpret these observations. There is an urgent need for an integrated One Health approach to understand the levels of human- and livestock-related clinical and asymptomatic disease and whether there is a need to implement interventions such as vaccination.

Patient-identified burden and unmet needs in patients with cluster headache: An evidence-based qualitative literature review

Objectives:

To qualitatively identify evidence-based literature related to the daily burden and unmet treatment and psychosocial needs of patients with cluster headache (CH).

Methods:

A literature search was conducted through October 20, 2020 across MEDLINE, EMBASE, CINAHL, and PsychInfo databases exploring quality of life (QoL) and disease burden in adults with CH. The search was restricted to full-text reports in peer-reviewed journals. Methodologic quality was assessed using the Critical Skills Appraisal Program.

Results:

From 11 identified publications, QoL was reduced in persons living with CH, with significant psychological, social, and socio-economic burdens, and work-related disability. The CH disease trajectory is complex, with patients experiencing the impact of their disease across multiple domains beyond the biological manifestation of the disease including stigma, employment limitations, and suicidal ideation, and with a lack of effective treatment from the patient perspective.

Discussion:

These findings strengthen comprehension of the CH patient experience, enabling a deeper understanding of the patients’ perspective and experience of their disease andunmet needs, providing a basis for future research into this debilitating condition. Minor limitations of this study include data extraction and study selection biases.

The Experiences of Caregivers of Persons Living with Dementia in Jamaica during COVID-19

This article provides descriptive insights of the experiences of family caregivers of persons living with dementia during the COVID-19 pandemic. Data were generated as part of a qualitative cross-national project to explore the costs and consequences of providing unpaid dementia care. Participants in Jamaica, who were recruited using community gatekeepers, information booths at health fairs, conferences, and other outreach events, were contacted by telephone to discuss their experiences of the pandemic. When face-to-face in-depth interview data collection was suspended due to the pandemic, ethical approval was received to contact all research participants who were informal unpaid family caregivers, both those whose care recipients had died and those who were active caregivers (N = 19). Participants in this study were the 10 active family caregivers (n_F = 8; aged 45+; 60% from high socio-economic status). Their updates and reflections during these calls were documented in fieldnotes and analyzed for key themes. Data showed that the pandemic has illustrated the direct costs, both financial and otherwise, that informal dementia carers bear in Jamaica. It also intensified pre-existing challenges faced by family carers. We provide recommendations for sustainable support for family carers.

Active inclusion of people living with dementia in planning for dementia care and services in low- and middle-income countries

Involving people living with dementia in service design and planning has become more common in high-income countries. It remains rare in low- and middle-income countries where two-thirds of the world's people with dementia live. In this commentary article, we explore the barriers to inclusion of people living with dementia in planning in low- and middle-income countries and make a case for the inclusion of people living with dementia in care and service planning. We suggest how this can be done at individual, community or national and state level using the following principles: 1) respecting the rights of people living with dementia to self-determination; 2) valuing people living with dementia's unique understanding of dementia; 3) creating a culture of active inclusion which creates a space for people living with dementia to participate and 4) ensuring appropriate accommodations are in place to maximise participation.

Beyond the project: Building a strategic theory of change to address dementia care, treatment and support gaps across seven middle-income countries

Evidence from middle-income countries indicates high and increasing prevalence of dementia and need for services. However, there has been little investment in care, treatment or support for people living with dementia and their carers. The Strengthening Responses to Dementia in Developing Countries (STRiDE) project aims to build both research capacity and evidence on dementia care and services in Brazil, Indonesia, India, Jamaica, Kenya, Mexico and South Africa. This article presents the Theory of Change (ToC) approach we used to co-design our research project and to develop a strategic direction for dementia care, treatment and support, with stakeholders. ToC makes explicit the process underlying how a programme will achieve its impact. We developed ToCs in each country and across the STRiDE project with researchers, practitioners, people living with dementia, carers and policymakers at different levels of government. This involved (1) an initial ToC workshop with all project partners (43 participants); (2) ToC workshops in each STRiDE country (22-49 participants in each); (3) comparison between country-specific and overall project ToCs; (4) review of ToCs in light of WHO dementia guidelines and action plan and (5) a final review. Our experiences suggest ToC is an effective way to generate a shared vision for dementia care, treatment and support among diverse stakeholders. However, the project contribution should be clearly delineated and use additional strategies to ensure appropriate participation from people living with dementia and their carers in the ToC process.

The utility of real-world evidence for benefit-risk assessment, communication, and evaluation of pharmaceuticals: Case studies

PURPOSE

In recent years, novel types of real-world evidence (RWE) have played a role in various decision-making processes relating to medicinal products, including regulatory approval, patient access, health technology assessment, safety monitoring, clinical use, and post-approval lifecycle management. We therefore reviewed the potential utility of RWE in the cycle of medicinal product benefit-risk (BR) assessment, communication/risk minimization and evaluation ("BRACE").

METHODS

A convenience sample of illustrative studies was drawn from the published literature and examined. Specifically, we examined the purpose for using RWE, the type of RWE used, its novelty and how it might be integrated with other data and activities of the BRACE cycle, and how it contributed to regulatory decision-making.

RESULTS

Eight studies were selected with each illustrating a different activity in the BRACE cycle ranging from BR assessment in the preapproval setting, post-approval assessment of safety or effectiveness, communicating BR information to patients and healthcare professionals, and evaluating the effectiveness of risk minimization initiatives to support a positive BR balance.

CONCLUSIONS

RWE has an important role in informing regulatory decision-making regarding the BR management of medicines. With increasing digitalization, facilitating data collection and stakeholder engagement in health, this role is only expected to expand in the future. To reach the full potential of RWE, both regulators and sponsors will need to be familiar with a range of existing and emerging methods for generating and analyzing such evidence appropriately and achieve convergence regarding how different types of RWE can best be used to inform BR management and decision-making.

Irreversible Electroporation For Hepatocellular Carcinoma: Longer-Term Outcomes At A Single Centre

BACKGROUND AND AIMS

Irreversible electroporation (IRE) is a non-thermal ablation technique for unresectable hepatocellular carcinoma (HCC) not amenable to standard thermal ablation. The aim of this study was to report our longer-term outcomes using this treatment modality.

METHOD

We identified all patients at our institution who underwent IRE for HCC between December 2008 and October 2019 as recommended after multi-disciplinary team review. Demographic, clinical, tumour response and survival data up until 1 March, 2020 were analysed. The primary outcome was local recurrence-free survival (LRFS) in patients who had a complete response (CR). Secondary outcomes included CR rates, procedure-related complications and the incidence of death or liver transplantation.

RESULTS

A total of 23 patients (78% males, median age 65.2 years) received IRE therapy to 33 HCC lesions during the study period with the median tumour size being 2.0 cm (range 1.0-5.0 cm). Twenty-nine (87.9%) lesions were successfully ablated after one (n = 26) or two (n = 3) procedures. The median follow-up time for these lesions was 20.4 months. The median overall LRFS was 34.5 (95% CI 24.8 -) months with a 6- and 12-month LRFS of 87.9% (95% CI 75.8-100) and 83.6% (95% CI 70.2-99.7), respectively. Tumours < 2 cm had a 12-month LRFS of 100% (95% CI 100-100).

CONCLUSION

IRE appears to be an efficacious local ablative method for early stage HCC not amenable to standard ablative techniques, with very good CR rates and longer-term LRFS, particularly for smaller lesions. Further studies comparing this technique to more widely accepted ablative methods such as radiofrequency and microwave ablation are warranted.

Tailoring and Remotely Switching Performance of Ultrafiltration Membranes by Magnetically Responsive Polymer Chains

Magnetically responsive ultrafiltration membranes were prepared by grafting poly(2-hydroxyethyl methacrylate) chains from the outer surface of 100-kDa regenerated cellulose ultrafiltration membranes. Surface-initiated atom transfer radical polymerization was used to graft the polymer chains. Grafting from the internal pore surface was suppressed by using glycerol as a pore-filling solvent during initiator immobilization at varied densities. Glycerol suppresses the initiator attachment to the pore surface. Polymerization times of up to four hours were investigated. Superparamagnetic nanoparticles were covalently attached to the chain end. Membrane performance was determined using bovine serum albumin and dextran as model solutes. Increasing the grafted polymer chain density and length led to a decrease in the permeate flux and an increase in the apparent rejection coefficient. In an oscillating magnetic field, movement of the grafted polymer chains led to a decrease in the permeate flux, as well as an increase in the apparent rejection coefficient of the model solutes.

A systematic review and meta-analysis of dementia prevalence in seven developing countries: A STRiDE project

The STRiDE project sets out to support the development of effective dementia policy in middle-income countries (Brazil, India, Indonesia, Jamaica, Kenya, Mexico, and South Africa). As part of this it will generate new data about the prevalence of dementia for a subset of these countries. This study aims to identify the current estimates of dementia prevalence in these countries and where the gaps lie in the current literature. A systematic review was completed on 30th April 2019 across electronic databases, identifying dementia prevalence literature originating from any of the seven countries. Four hundred and twenty-nine records were identified following de-duplication; 28 studies met the inclusion criteria and were included in the systematic review. Pooled estimates of dementia prevalence ranged from 2% to 9% based on DSM-IV criteria; these figures were generally higher in studies using other diagnostic criteria (e.g. the 10/66 algorithm). Available prevalence data varied between countries. Only Brazil, Mexico and India had data derived from studies judged as having a low risk of bias. Irrespective of country, studies often were not explicit in detailing the representativeness of their sample, or whether there was non-response bias. Further transparent and externally valid dementia prevalence research is needed across the STRiDE countries.

Development of the influence, motivation, and patient activation in diabetes (IMPACT-D™) measure

AIMS

We sought to create a new research and clinical instrument -the Influence and Motivation for Patient ACTivation in Diabetes care (IMPACT-D™) - to measure the degree to which patients with type 2 diabetes (T2DM) value health and believe they can influence it.

METHODS

Candidate items were generated via a literature review, expert opinion, and qualitative interviews and focus groups with T2DM patients in Chicago, IL and Chapel Hill, NC. Psychometric testing guided by item response theory was conducted among an online panel of 500 English-speaking adults with T2DM. Differential item functioning analyses evaluated item performance across key participant characteristics. To determine construct validity, IMPACT-D™ scores were compared to other general measures of personality and patient activation. A second study among 300 patients recruited from two internal medicine clinics further assessed associations between the IMPACT-D™ and health outcomes. Cognitive interviews confirmed patient understanding of IMPACT-D™ items and instructions.

RESULTS

Exploratory factor analyses revealed a single-factor solution that included 6 items. The IMPACT-D™ demonstrated adequate reliability (α = 0.72) and moderate construct validity with patient activation (r = 0.51, p < 0.001) and personality-conscientiousness subscales (r = 0.29, p < 0.001). Higher scores on the IMPACT-D™ were associated with better physical health (r = 0.17, p = 0.003) and lower severity of depressive (r = -0.35, p < 0.001) and anxiety (r = -0.28, p < 0.001) symptoms. There were no significant differences by blood pressure (r = -0.0021, p = 0.9) or haemoglobin A1c (r = -0.069p = 0.2).

CONCLUSIONS

The IMPACT-D holds potential for use in both clinical care and research applications. Future studies should evaluate how to best operationalize its use for both settings.

Implementation and dissemination of an African American popular opinion model to improve lupus awareness: an academic-community partnership

OBJECTIVE

Lupus is a chronic, autoimmune disease that disproportionately affects African Americans. We adapted the Centers for Disease Control and Prevention's Popular Opinion Leader model to implement an intervention tailored for African American individuals that leverages an academic-community partnership and community-based social networks to disseminate culturally appropriate lupus education.

METHODS

Academic rheumatologists, social scientists, and researchers in Boston, MA and Chicago, IL partnered with local lupus support groups, community organizations, and churches in neighborhoods with higher proportions of African Americans to develop curriculum and recruit community leaders with and without lupus (Popular Opinion Leaders; POLs). POLs attended four training sessions focused on lupus education, strategies to educate others, and a review of research methods. POLs disseminated information through their social networks and recorded their impact, which was mapped using a geographic information system framework.

RESULTS

We trained 18 POLs in greater Boston and 19 in greater Chicago: 97% were African American, 97% were female; and the mean age was 57 years. Fifty-nine percent of Boston POLs and 68% of Chicago POLs had lupus. POLs at both sites engaged members of their social networks and communities in conversations about lupus, health disparities, and the importance of care. Boston POLs documented 97 encounters with 547 community members reached. Chicago POLs documented 124 encounters with 4083 community members reached.

CONCLUSIONS

An adapted, community-based POL model can be used to disseminate lupus education and increase awareness in African American communities. Further research is needed to determine the degree to which this may begin to reduce disparities in access to care and outcomes.

Reduction in Length of Stay and Morphine Use for NAS With the "Eat, Sleep, Console" Method

OBJECTIVES

To reduce average length of stay (ALOS) in infants with neonatal abstinence syndrome (NAS) transferred to the inpatient floor from the mother-infant unit. Secondarily, we aimed to reduce morphine exposure in these infants.

METHODS

Using quality improvement methodology, we redesigned our approach to NAS on the inpatient floor. Key interventions included transitioning from a modified Finnegan Neonatal Abstinence Scoring System to the "Eat, Sleep, Console" method for withdrawal assessment, reeducation on nonpharmacologic interventions, and adding as-needed morphine as initial pharmacotherapy. Data for infants ≥35 weeks' gestation with confirmed in utero opioid exposure and worsening symptoms of NAS requiring transfer to the inpatient floor were obtained, including ALOS, number of morphine doses, and total morphine amount administered. Infants with conditions requiring nothing by mouth for >12 hours or morphine initiation in the ICU were excluded.

RESULTS

ALOS for infants (baseline n = 40; intervention n = 36) with NAS transferred to the inpatient floor decreased from 10.3 to 4.9 days. Average morphine administered decreased from 38 to 0.3 doses per infant. No infant in the intervention period required scheduled morphine. The percent of all infants transferred to the floor for NAS requiring any morphine decreased from 92% at baseline to 19% postimplementation. There were no observed adverse events or NAS-related readmissions in the intervention period.

CONCLUSIONS

Transitioning to the Eat, Sleep, Console assessment with re-enforcement of nonpharmacologic care and use of as-needed morphine as initial pharmacotherapy resulted in a notably decreased ALOS and near elimination of postnatal opioid treatment of infants with NAS managed on our inpatient floor.

Unexplained Practice Variation in Primary Care Providers' Concern for Pediatric Obstructive Sleep Apnea

OBJECTIVE

To examine primary care provider (PCP) screening practice for obstructive sleep apnea (OSA) and predictive factors for screening habits. A secondary objective was to describe the polysomnography completion proportion and outcome. We hypothesized that both provider and child health factors would predict PCP suspicion of OSA.

METHODS

A computer decision support system that automated screening for snoring was implemented in 5 urban primary care clinics in Indianapolis, Indiana. We studied 1086 snoring children aged 1 to 11 years seen by 26 PCPs. We used logistic regression to examine the association between PCP suspicion of OSA and child demographics, child health characteristics, provider characteristics, and clinic site.

RESULTS

PCPs suspected OSA in 20% of snoring children. Factors predicting PCP concern for OSA included clinic site (P < .01; odds ratio [OR] = 0.13), Spanish language (P < .01; OR = 0.53), provider training (P = .01; OR = 10.19), number of training years (P = .01; OR = 4.26) and child age (P < .01), with the youngest children least likely to elicit PCP concern for OSA (OR = 0.20). No patient health factors (eg, obesity) were significantly predictive. Proportions of OSA suspicion were variable between clinic sites (range, 6-28%) and between specific providers (range, 0-63%). Of children referred for polysomnography (n = 100), 61% completed the study. Of these, 67% had OSA.

CONCLUSIONS

Results suggest unexplained small area practice variation in PCP concern for OSA among snoring children. It is likely that many children at risk for OSA remain unidentified. An important next step is to evaluate interventions to support PCPs in evidence-based OSA identification.

Erythropoietin Upregulates Brain Hemoglobin Expression and Supports Neuronal Mitochondrial Activity

Multiple sclerosis (MS) is a neuro-inflammatory and demyelinating disease. Downregulation of neuronal mitochondrial gene expression and activity have been reported in several studies of MS. We have previously shown that hemoglobin-β (Hbb) signals to the nucleus of neurons and upregulates H3K4me3, a histone mark involved in regulating cellular metabolism and differentiation. The present study was undertaken to evaluate the effect of erythropoietin (EPO) on the upregulation of hemoglobin and mitochondrial-associated neuroprotection. We found that administering EPO (5000 IU/kg intraperitoneally) to mice upregulated brain Hbb expression, levels of H3K4me3, expression of mitochondrial complex III, complex V, and mitochondrial respiration. We also found that the neuronal mitochondrial metabolite N-acetylaspartate (NAA), a marker of neuronal mitochondrial activity, was increased with EPO treatment. Further, we measured the effects of EPO on preventing mitochondrial deficits in the cuprizone toxic demyelinating mouse model of MS. We found that EPO prevented cuprizone-mediated decreases in Hbb, complex III, and NAA. Our data suggest that EPO mediated regulation of Hbb supports neuronal energetics and may provide neuroprotection in MS and other neurodegenerative diseases where a dysfunction of mitochondria contributes to disease.

Trajectories of women's abortion-related care: A conceptual framework

We present a new conceptual framework for studying trajectories to obtaining abortion-related care. It assembles for the first time all of the known factors influencing a trajectory and encourages readers to consider the ways these macro- and micro-level factors operate in multiple and sometimes conflicting ways. Based on presentation to and feedback from abortion experts (researchers, providers, funders, policymakers and advisors, advocates) (n = 325) between 03/06/2014 and 22/08/2015, and a systematic mapping of peer-reviewed literature (n = 424) published between 01/01/2011 and 30/10/2017, our framework synthesises the factors shaping abortion trajectories, grouped into three domains: abortion-specific experiences, individual contexts, and (inter)national and sub-national contexts. Our framework includes time-dependent processes involved in an individual trajectory, starting with timing of pregnancy awareness. This framework can be used to guide testable hypotheses about enabling and inhibiting influences on care-seeking behaviour and consideration about how abortion trajectories might be influenced by policy or practice. Research based on understanding of trajectories has the potential to improve women's experiences and outcomes of abortion-related care.

Dysregulation of methionine metabolism in multiple sclerosis

We report a significant reduction in plasma methionine concentrations in relapse remitting multiple sclerosis (MS) patients compared to controls. In vivo studies demonstrate that changes in peripheral methionine levels in mice can regulate histone H3 methylation and expression of DNA methyltransferase 3A (DNMT3A) centrally, in the cerebral cortex. Therefore, we propose that decreases in circulating methionine represent one of the earliest manifestations of dysregulated methionine metabolism in MS with potential impacts on both histone H3 and DNA methylation in the central nervous system.

Improving the magnetoelectric performance of Metglas/PZT laminates by annealing in a magnetic field

A comprehensive investigation of magnetostriction optimization in Metglas 2605SA1 ribbons is performed to enhance magnetoelectric performance. We explore a range of annealing conditions to relieve remnant stress and align the magnetic domains in the Metglas, while minimizing unwanted crystallization. The magnetostriction coefficient, magnetoelectric coefficient, and magnetic domain alignment are correlated to optimize magnetoelectric performance. We report on direct magnetostriction observed by in-plane Doppler vibrometer and domain imagining using scanning electron microscopy with polarization analysis for a range of annealing conditions. We find that annealing in an oxygen-free environment at 400 °C for 30 min yields an optimal magnetoelectric coefficient, magnetostriction and magnetostriction coefficient. The optimized ribbons had a magnetostriction of 50.6 ± 0.2 μm m-1 and magnetoelectric coefficient of 79.3 ± 1.5 μm m-1 mT-1. The optimized Metglas 2605SA1 ribbons and PZT-5A (d31 mode) sensor achieves a magnetic noise floor of approximately 600 pT Hz-1/2 at 100 Hz and a magnetoelectric coefficient of 6.1 ± 0.03 MV m-1 T-1.

Radiocarbon constraints on the glacial ocean circulation and its impact on atmospheric CO2

While the ocean’s large-scale overturning circulation is thought to have been significantly different under the climatic conditions of the Last Glacial Maximum (LGM), the exact nature of the glacial circulation and its implications for global carbon cycling continue to be debated. Here we use a global array of ocean–atmosphere radiocarbon disequilibrium estimates to demonstrate a ∼689±53 ¹⁴C-yr increase in the average residence time of carbon in the deep ocean at the LGM. A predominantly southern-sourced abyssal overturning limb that was more isolated from its shallower northern counterparts is interpreted to have extended from the Southern Ocean, producing a widespread radiocarbon age maximum at mid-depths and depriving the deep ocean of a fast escape route for accumulating respired carbon. While the exact magnitude of the resulting carbon cycle impacts remains to be confirmed, the radiocarbon data suggest an increase in the efficiency of the biological carbon pump that could have accounted for as much as half of the glacial–interglacial CO₂ change.

Establishing the efficiency of the biological carbon pump is needed to constrain the impact of ocean circulation on the carbon cycle. Here, the authors compile a global array of ocean–atmosphere radiocarbon disequilibrium estimates and evaluate the strength of the carbon pump over the last glacial maximum.

Neither 'foolish' nor 'finished': identity control among older adults with HIV in rural Malawi

Prevalence of HIV after age 50 is considerable, especially in southern Africa. Negative social constructions of HIV in older age, and the health consequences of ageing with the virus, mean that having HIV presents a challenge for many people's roles and social memberships, threatening to disrupt their sense of self. Using constructivist grounded theory and qualitative data from rural Malawi, this paper describes how older men and women deal with these identity challenges. Drawing on a symbolic interactionist framework, it uses identity control theory to explore how the study's participants presented their post-diagnosis behaviours in ways that maintained their most significant pre-diagnosis identities as 'adults', a label they gave to the core identity of being a person who belongs in the social world. Considering the processes through which older people with HIV navigated challenges to their identities in light of the intersectional influences of HIV and age-related stigma and illness, provides insight into how older people might experience HIV, as well as informing theoretical understandings of identity formation and maintenance in light of chronic and/or stigmatising illness more broadly.

The neuronal metabolite NAA regulates histone H3 methylation in oligodendrocytes and myelin lipid composition

The neuronal mitochondrial metabolite N-acetylaspartate (NAA) is decreased in the multiple sclerosis (MS) brain. NAA is synthesized in neurons by the enzyme N-acetyltransferase-8-like (NAT8L) and broken down in oligodendrocytes by aspartoacylase (ASPA) into acetate and aspartate. We have hypothesized that NAA links the metabolism of axons with oligodendrocytes to support myelination. To test this hypothesis, we performed lipidomic analyses using liquid chromatography-tandem mass spectrometry (LC-MS/MS) and high-performance thin-layer chromatography (HPTLC) to identify changes in myelin lipid composition in postmortem MS brains and in NAT8L knockout (NAT8L^-/-) mice which do not synthesize NAA. We found reduced levels of sphingomyelin in MS normal appearing white matter that mirrored decreased levels of NAA. We also discovered decreases in the amounts of sphingomyelin and sulfatide lipids in the brains of NAT8L^-/- mice compared to controls. Metabolomic analysis of primary cultures of oligodendrocytes treated with NAA revealed increased levels of α-ketoglutarate, which has been reported to regulate histone demethylase activity. Consistent with this, NAA treatment resulted in alterations in the levels of histone H3 methylation, including H3K4me3, H3K9me2, and H3K9me3. The H3K4me3 histone mark regulates cellular energetics, metabolism, and growth, while H3K9me3 has been linked to alterations in transcriptional repression in developing oligodendrocytes. We also noted the NAA treatment was associated with increases in the expression of genes involved in sulfatide and sphingomyelin synthesis in cultured oligodendrocytes. This is the first report demonstrating that neuronal-derived NAA can signal to the oligodendrocyte nucleus. These data suggest that neuronal-derived NAA signals through epigenetic mechanisms in oligodendrocytes to support or maintain myelination.

Is there an opportunity to reduce urinary catheter-related infections? Exploring variation in catheterisation rates in care homes

rinary catheterisation in care homes is associated with increased morbidity, hospitalisation and mortality. The authors aimed to determine whether staffing, resident underlying illness or nursing band, or use of other toileting methods were responsible for the wide variation in urinary catheterisation rates found in English care homes. The authors approached randomly-selected registered care homes in three former health districts in England. A questionnaire survey was used to determine the number of residents in each nursing care band and with different medical conditions that were catheterised, and the home's management of residents' continence. The number of residents or staffing did not influence catheterisation rate. Higher catheterisation rate homes had a lower proportion of high band nursing residents and residents with incontinence, severe physical disability and dementia than the other homes. Only urinary retention (3 per cent of residents) was significantly more common in the higher catheterisation rate homes. There was no difference in continence care before inserting a catheter. The authors suggest that care culture and staff attitudes to catheterisation should be explored in greater depth using structured interviews or focus groups. This may allow the identification of key factors that can be targeted in order to reduce catheterisation rates and the associated morbidity.

Understanding HIV-related stigma in older age in rural Malawi

The combination of HIV- and age-related stigma exacerbates prevalence of HIV infection and late diagnosis and initiation of anti-retroviral therapy among older populations (Moore, 2012; Richards et al. 2013). Interventions to address these stigmas must be grounded in understanding of situated systems of beliefs about illness and older age. This study analyses constructions of HIV and older age that underpinned the stigmatisation of older adults with HIV in rural Balaka, Malawi. It draws on data from a series of in-depth interviews (N = 135) with adults aged 50-∼90 (N = 43) in 2008-2010. Around 40% (n = 18) of the sample had HIV. Dominant understandings of HIV in Balaka pertained to the sexual transmission of the virus and poor prognosis of those infected. They intersected with understandings of ageing. Narratives about older age and HIV in older age both centred on the importance of having bodily, moral and social power to perform broadly-defined "work". Those who could not work were physically and socially excluded from the social world. This status, labelled as "child-like", was feared by all participants. In participants' narratives, growing old involves a gradual decline in the power required to produce one's membership of the social world through work. HIV infection in old age is understood to accelerate this decline. Understandings of the sexual transmission of HIV, in older age, imply the absence of moral power and in turn, loss of social power. The prognosis of those with HIV, in older age, reflects and causes amplified loss of bodily power. In generating dependency, this loss of bodily power infantilises older care recipients and jeopardises their family's survival, resulting in further loss of social power. This age-and HIV-related loss of power to produce social membership through work is the discrediting attribute at the heart of the stigmatisation of older people with HIV.

Field Effect and Strongly Localized Carriers in the Metal-Insulator Transition Material VO(2)

The intrinsic field effect, the change in surface conductance with an applied transverse electric field, of prototypal strongly correlated VO(2) has remained elusive. Here we report its measurement enabled by epitaxial VO(2) and atomic layer deposited high-κ dielectrics. Oxygen migration, joule heating, and the linked field-induced phase transition are precluded. The field effect can be understood in terms of field-induced carriers with densities up to ∼5×10(13)  cm(-2) which are trongly localized, as shown by their low, thermally activated mobility (∼1×10(-3)  cm(2)/V s at 300 K). These carriers show behavior consistent with that of Holstein polarons and strongly impact the (opto)electronics of VO(2).

Lead optimization toward proof-of-concept tools for Huntington's disease within a 4-(1H-pyrazol-4-yl)pyrimidine class of pan-JNK inhibitors

Through medicinal chemistry lead optimization studies focused on calculated properties and guided by X-ray crystallography and computational modeling, potent pan-JNK inhibitors were identified that showed submicromolar activity in a cellular assay. Using in vitro ADME profiling data, 9t was identified as possessing favorable permeability and a low potential for efflux, but it was rapidly cleared in liver microsomal incubations. In a mouse pharmacokinetics study, compound 9t was brain-penetrant after oral dosing, but exposure was limited by high plasma clearance. Brain exposure at a level expected to support modulation of a pharmacodynamic marker in mouse was achieved when the compound was coadministered with the pan-cytochrome P450 inhibitor 1-aminobenzotriazole.

Bicycling policy indirectly associated with overweight/obesity

BACKGROUND

Policies to enhance bicycling are correlated with health outcomes. Research has yet to provide an adequate, empirically derived explanation for this finding.

PURPOSE

To examine a comprehensive model of a pathway potentially linking bicycle policies to overweight/obesity.

METHODS

Data representing multiple years between 2006 and 2012 from CDC, U.S. Census Bureau, U.S. Department of Transportation, and the Alliance for Biking and Walking were subjected to bivariate and multivariate analyses in 2013. A path model was created to explain the relationship between bicycle policies and overweight/obesity in the 48 largest U.S. cities.

RESULTS

Zero-order correlations were significant between the number of bicycle policies and the percentage of workers bicycling to work and rates of overweight/obesity. These relationships did not remain statistically significant in the multivariate analysis. However, more bicycle policies were associated with a greater number of bicycle infrastructure components (p<0.005). In turn, bicycling infrastructure components were positively related to the percentage of workers bicycling to work (p<0.001), which was inversely associated with overweight/obesity rates (p<0.05).

CONCLUSIONS

The results of this study suggest that large cities with more policies aimed at promoting bicycling have fewer overweight/obese residents, partially because the policies are related to supportive bicycling infrastructures that promote bicycling to work.

Decreased NAA in gray matter is correlated with decreased availability of acetate in white matter in postmortem multiple sclerosis cortex

Multiple sclerosis (MS) is an inflammatory neurodegenerative disease of the central nervous system (CNS) which leads to progressive neurological disability. Our previous studies have demonstrated mitochondrial involvement in MS cortical pathology and others have documented decreased levels of the neuronal mitochondrial metabolite N-acetyl aspartate (NAA) in the MS brain. While NAA is synthesized in neurons, it is broken down in oligodendrocytes into aspartate and acetate. The resulting acetate is incorporated into myelin lipids, linking neuronal mitochondrial function to oligodendrocyte-mediated elaboration of myelin lipids in the CNS. In the present study we show that treating human SH-SY5Y neuroblastoma cells with the electron transport chain inhibitor antimycin A decreased levels of NAA as measured by HPLC. To better understand the significance of the relationship between mitochondrial function and levels of NAA and its breakdown product acetate on MS pathology we then quantitated the levels of NAA and acetate in MS and control postmortem tissue blocks. Regardless of lesion status, we observed that levels of NAA were decreased 25 and 32 % in gray matter from parietal and motor cortex in MS, respectively, compared to controls. Acetate levels in adjacent white matter mirrored these decreases as evidenced by the 36 and 45 % reduction in acetate obtained from parietal and motor cortices. These data suggest a novel mechanism whereby mitochondrial dysfunction and reduced NAA levels in neurons may result in compromised myelination by oligodendrocytes due to decreased availability of acetate necessary for the synthesis of myelin lipids.