Intracellular S-adenosylhomocysteine concentrations predict global DNA hypomethylation in tissues of methyl-deficient cystathionine beta-synthase heterozygous mice

Because S-adenosylmethionine (SAM) and S-adenosylhomocysteine (SAH) are the substrate and product of essential methyltransferase reactions; the ratio of SAM:SAH is frequently used as an indicator of cellular methylation potential. However, it is not clear from the ratio whether substrate insufficiency, product inhibition or both are required to negatively affect cellular methylation capacity. A combined genetic and dietary approach was used to modulate intracellular concentrations of SAM and SAH. Wild-type (WT) or heterozygous cystathionine beta-synthase (CBS +/-) mice consumed a control or methyl-deficient diet for 24 wk. The independent and combined effect of genotype and diet on SAM, SAH and the SAM:SAH ratio were assessed in liver, kidney, brain and testes and were correlated with relative changes in tissue-specific global DNA methylation. The combined results from the different tissues indicated that a decrease in SAM alone was not sufficient to affect DNA methylation in this model, whereas an increase in SAH, either alone or associated with a decrease in SAM, was most consistently associated with DNA hypomethylation. A decrease in SAM:SAH ratio was predictive of reduced methylation capacity only when associated with an increase in SAH; a decrease in the SAM:SAH ratio due to SAM depletion alone was not sufficient to affect DNA methylation in this model. Plasma homocysteine levels were positively correlated with intracellular SAH levels in all tissues except kidney. These results support the possibility that plasma SAH concentrations may provide a sensitive biomarker for cellular methylation status.

The effect of exercise on neuropathic symptoms, nerve function, and cutaneous innervation in people with diabetic peripheral neuropathy

Although exercise can significantly reduce the prevalence and severity of diabetic complications, no studies have evaluated the impact of exercise on nerve function in people with diagnosed diabetic peripheral neuropathy (DPN). The purpose of this pilot study was to examine feasibility and effectiveness of a supervised, moderately intense aerobic and resistance exercise program in people with DPN. We hypothesized that the exercise intervention can improve neuropathic symptoms, nerve function, and cutaneous innervation.

METHODS

A pre-test post-test design was used to assess change in outcome measures following participation in a 10-week aerobic and strengthening exercise program. Seventeen subjects with diagnosed DPN (8 males/9 females; age 58.4±5.98; duration of diabetes 12.4±12.2 years) completed the study. Outcome measures included pain measures (visual analog scale), Michigan Neuropathy Screening Instrument (MNSI) questionnaire of neuropathic symptoms, nerve function measures, and intraepidermal nerve fiber (IENF) density and branching in distal and proximal lower extremity skin biopsies.

RESULTS

Significant reductions in pain (-18.1±35.5 mm on a 100 mm scale, P=.05), neuropathic symptoms (-1.24±1.8 on MNSI, P=.01), and increased intraepidermal nerve fiber branching (+0.11±0.15 branch nodes/fiber, P=.008) from a proximal skin biopsy were noted following the intervention.

CONCLUSIONS

This is the first study to describe improvements in neuropathic and cutaneous nerve fiber branching following supervised exercise in people with diabetic peripheral neuropathy. These findings are particularly promising given the short duration of the intervention, but need to be validated by comparison with a control group in future studies.

Uteroplacental insufficiency affects epigenetic determinants of chromatin structure in brains of neonatal and juvenile IUGR rats

Intrauterine growth retardation (IUGR) increases the risk of neuroendocrine reprogramming. In the rat, IUGR leads to persistent changes in cerebral mRNA levels. This suggests lasting alterations in IUGR cerebral transcriptional regulation, which may result from changes in chromatin structure. Candidate nutritional triggers for these changes include altered cerebral zinc and one-carbon metabolite levels. We hypothesized that IUGR affects cerebral chromatin structure in neonatal and postnatal rat brains. Rats were rendered IUGR by bilateral uterine artery ligation; controls (Con) underwent sham surgery. At day of life 0 (d0), we measured cerebral DNA methylation, histone acetylation, expression of chromatin-affecting enzymes, and cerebral levels of one-carbon metabolites and zinc. At day of life 21 (d21), we measured cerebral DNA methylation and histone acetylation, as well as the caloric content of Con and IUGR rat breast milk. At d0, IUGR significantly decreased genome-wide and CpG island methylation, as well as increased histone 3 lysine 9 (H3/K9) and histone 3 lysine 14 (H3/K14) acetylation in the hippocampus and periventricular white matter, respectively. IUGR also decreased expression of the chromatin-affecting enzymes DNA methyltransferase 1 (DNMT1), methyl-CpG binding protein 2 (MeCP2), and histone deacetylase (HDAC)1 in association with increased cerebral levels of zinc. In d21 female IUGR rats, cerebral CpG DNA methylation remained lower, whereas H3/K9 and H3/K14 hyperacetylation persisted in hippocampus and white matter, respectively. In d21 male rats, IUGR decreased acetylation of H3/K9 and H3/K14 in these respective regions compared with controls. Despite these differences, caloric, fat, and protein content were similar in breast milk from Con and IUGR dams. We conclude that IUGR results in postnatal changes in cerebral chromatin structure and that these changes are sex specific.

A Subgroup of Chronic Low Back Pain Patients With Central Sensitization

BACKGROUND

Our knowledge of central sensitization (CS) in chronic low back pain (CLBP) is limited. 2011 fibromyalgia criteria and severity scales (2011 FM survey) have been used to determine FM positive as a surrogate of CS. The major features of CS including widespread hyperalgesia and dysfunction of the descending inhibitory pathways can be identified by pressure pain threshold (PPT) and conditioned pain modulation (CPM) tests. The purpose of the study was to examine neurophysiological characteristics and psychosocial symptoms in a subgroup of FM-positive CLBP compared with FM-negative CLBP patients.

METHODS

A total of 46 participants with CLBP and 22 pain-free controls completed outcome measures of the 2011 FM survey, PPT and CPM tests, and psychosocial questionnaires. Differences between FM-positive and FM-negative CLBP participants on these measures and correlations were analyzed.

RESULTS

The 2011 FM survey identified 22 (48%) participants with CLBP as FM positive. FM-positive CLBP participants showed lower PPT values of the thumbnail (P=0.011) and lower back (P=0.003), lower CPM values of the thumbnail (P=0.002), and more severe pain catastrophizing, anxiety, and depression symptoms (P<0.05) than FM-negative CLBP participants. The 2011 FM scores were significantly correlated with the PPT and CPM values of the thumbnail and with psychosocial symptoms (P<0.001).

DISCUSSION

Our findings suggest a subgroup of CLBP patients exhibiting with signs and symptoms of CS. Associations between subjective and objective CS measures indicate that the 2011 FM survey can be utilized to identify the presence of CS in CLBP in clinical practice.

Congenital heart defects and genetic variants in the methylenetetrahydroflate reductase gene

BACKGROUND

Most non-syndromic congenital heart defects (CHD) are caused by a complex interaction between maternal lifestyle factors, environmental exposures, and maternal and fetal genetic variants. Maternal periconceptional intake of folic acid containing vitamin supplements is reported to decrease the risk of CHD. The 677C-->T and 1298A-->C polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene decrease enzyme activity.

OBJECTIVE

To examine the relation between CHD and maternal and fetal MTHFR polymorphisms.

METHODS

375 nuclear families were studied. The transmission/disequilibrium test was used to test for transmission distortion in complete triads. A log-linear approach was used to test for associations between CHD and maternal and offspring polymorphisms, and to estimate independently the contributions of maternal and fetal variants to relative risks. Haplotype frequencies were estimated and a haplotype transmission disequilibrium test carried out.

RESULTS

The 1298C allele was transmitted less often than expected (p = 0.0013). There was no distortion in the transmission of the 677T allele, neither was there evidence of a parent of origin effect in the transmission of either of the single nucleotide polymorphisms. The 677C-1298C haplotype was also transmitted less often than expected (p = 0.0020). The relative risk associated with inheriting one copy of the 1298C allele was 0.64 (95% confidence interval, 0.48 to 0.87) and the that associated with inheriting two copies of the 1298C allele, 0.38 (0.21 to 0.70).

CONCLUSIONS

The apparent protective effect of the MTHFR 1298C allele against CHD could have several explanations and further study is needed.

Brief report: an empirically derived educational program for detecting and preventing skin cancer

College and high-school students were administered a questionnaire to assess their knowledge about skin cancer, and afterward an educational program was designed to correct the identified deficiencies. Results showed that the students were relatively uniformed about how to recognize and prevent skin cancer--high-school students more so than college students--but that their knowledge of the disease (e.g., risk factors, preventive measures, and identification of "warning signs" for early detection) increased significantly after training. Some forgetting was noted at a 2-week follow-up but knowledge levels were still significantly higher than baseline. If these findings are representative of the general population, more preventive education will be needed in this area. This is especially true because the potentially deadly melanoma appears to be increasing at an alarming rate.

Early biomechanical markers of postural instability in Parkinson's disease

Current clinical assessments do not adequately detect the onset of postural instability in the early stages of Parkinson's disease (PD). The aim of this study was to identify biomechanical variables that are sensitive to the effects of early Parkinson's disease on the ability to recovery from a balance disturbance. Ten adults diagnosed with idiopathic PD and no clinically detectable postural instability, and ten healthy age-range matched controls (HC) completed the study. The first step in the response to a backwards waist pull was quantified in terms of strategy, temporal, kinematic, kinetic, and center of pressure (COP) variables. People with PD, compared to HC, tended to be less consistent in the choice of stepping limb, utilized more time for weight shift, used a modified ankle joint motion prior to liftoff, and the COP was further posterior at landing. The study results demonstrate that PD changes the response to a balance disturbance which can be quantified using biomechanical variables even before the presence of clinically detectable postural instability. Further studies are required to determine if these variables are sensitive and specific to postural instability.

Determining the impact of an interprofessional learning in practice model on learners and patients

The Institute of Medicine recently expressed a need to measure the impact of interprofessional education (IPE) on health professions collaborative behavior in practice environments and patient outcomes, and the National Center for Interprofessional Practice and Education has focused research efforts to connect interprofessional practice and education. We describe a model intentionally designed to link interprofessional practice experience in ambulatory care setting and an IPE curriculum for students, called the Interprofessional Learning in Practice (ILIP) model. The study objective was to determine the impact of the ILIP model on student and patient outcomes during a 24-month intervention period. Student satisfaction was collected through a brief survey administered post-ILIP model. Patient outcomes were collected from before and after the intervention period through a retrospective chart review of patients who received care through the ILIP model. For the study, disease indicators for the top three chronic diagnoses of depression, hypertension, and type 2 diabetes mellitus were chosen as the patient outcomes. Student outcomes were analyzed using descriptive statistics and the Mann-Whitney U test. Patient outcomes were analyzed using McNemar's test and paired t-tests. Of the 382 students who participated in the ILIP model during the study period, 179 completed surveys, indicating that they valued the experience, valued learning from interprofessional preceptors, and gained interprofessional skills to use in their future practice. During the 24-month intervention, 401 patients were evaluated post-ILIP model, statistically significant results demonstrated HbA1c values for patients with diabetes were reduced by 0.5% and depression screening improved from 9% to 91%. Additionally, patients' hypertension control was similar to baseline and diabetes control (as defined as HbA1c ≤8%) was improved compared to baseline but did not reach statistical significance. By aligning interprofessional practice and education in the ILIP model, students had a positive experience, gained interprofessional collaboration skills, and provided value-added benefits to improve patient outcomes.

A Validation Study of the Missouri Alliance for Home Care Fall Risk Assessment Tool

A retrospective review ( n = 2,247) was conducted from July 1st to October 1st 2010 to determine validity of the Missouri Alliance for Home Care Fall Risk Assessment Tool (MAHC-10). Fall risk was identified by a MAHC-10 score ≥ 4. Two sample t test, chi-square, logistic regression, and ROC curve analyses were performed. Fallers (6.35 ± 1.7, n = 195) and nonfallers (5.70 ± 1.9, n = 2,052) had significantly different ( p = .011) MAHC-10 scores. The MAHC-10 cutoff score of 4 demonstrated 96.9% sensitivity and 13.3% specificity; however, ROC curve analyses revealed a cutoff score of 6 maximized combined sensitivity and specificity. The MAHC-10 is valid for fall risk screening in the home health setting; however, a cutoff score of 6 may more accurately predict fall risk.

Preparing a healthcare workforce for geriatrics care: an Interprofessional team based learning program

Background

Improving the care of older adults in our healthcare system involves teams working together. As the geriatrics population rises globally, health science learners need to be prepared to work collaboratively to recognize and treat common conditions in geriatrics. To enable workforce preparation, the Institute of Medicine and the National League for Nursing emphasize the need to implement interprofessional active learning activities for undergraduate healthcare learners at academic medical centers.

Methods

The Geriatrics Champions Program was a team-based learning activity created to meet this task. It was a 24-month program, repeated twice, that impacted 768 learners and 151 faculty from medicine, occupational therapy, physical therapy, nursing, social welfare, psychology, pharmacy and dietetics. Each class was intentionally divided into 20 interprofessional teams that met four times annually. Each session focused on one geriatrics domain. The objectives were centered around the specific geriatrics competencies for each health profession, divided into the eight domains written in the “American Geriatrics Society IM-FM Residency Competencies”. Evaluation consisted of individual and team Readiness Assessment Tests (iRAT and tRAT). Surveys were also used to collect feedback using a Likert scale. Wilcoxon signed rank tests were used to compare iRAT and tRAT scores. Other analyses identified characteristics associated with tRAT performance group (Unpaired t-tests) and tRAT performance on the raw scale (Pearson correlation). Paired t-tests using a 7-level Likert Scale measured pre-post change in learner knowledge.

Results

Student tRAT scores were 30% higher than iRAT scores (p < 0.001). Teams were more likely to score 100% on the initial tRAT attempt if more team members attended the current session (p < 0.001), more health professions were represented by team members in attendance (p = 0.053), and the team had a better track record of past attendance (p < 0.01). In the post-program evaluation, learners felt this program was helpful for their career preparation in interprofessional geriatrics care.

Conclusions

Learners understood that teams performed better than individuals in the care of older adults. Feedback from the learners and faculty was consistently positive and learners felt better prepared for geriatrics care. The program’s benefits may extend beyond individual sessions.

An interprofessional objective structured teaching experience (iOSTE): An interprofessional preceptor professional development activity

There has been a recent shift to develop and implement interprofessional education for learners during their "clinical" years. With this shift comes a specific need to develop preceptors in the area of interprofessional precepting. The interprofessional objective structured teaching experience (iOSTE) is one method for developing preceptors. The iOSTE was developed from experience with an interprofessional teaching clinic. Full and short versions of the iOSTE were implemented across multiple universities. The iOSTE gives preceptors an opportunity to gain experience with key skills associated with precepting interprofessional learners in clinical settings. Participants evaluated the iOSTE after the session using Likert scale ratings and open-ended questions. Descriptive statistics, independent samples T-tests, and content analysis were used to analyse the data. A total of 96 individuals from 15 different professions and three different universities participated in the iOSTE, with 59.4% (n = 57) completing the iOSTE evaluation. The iOSTE was highly rated with significant differences between the full and short versions of the iOSTE for three evaluation items. Content analysis revealed common themes that preceptors took away from the experience were of "all voices included" and "interprofessional precepting skills". Overall, the iOSTE appears to a feasible and effective method for developing interprofessional preceptors.

Interprofessional Medication Error Disclosure Training Using a Telehealth Consultation Simulation

Objective. Health professions students must develop collaborative skills to disclose errors effectively and improve patient safety. We proposed that an interprofessional simulation using telehealth technology would provide medical and pharmacy students the opportunity to practice, develop, and grow in their confidence and skills of working collaboratively and disclosing medication errors.Methods. A three-phase interprofessional student simulation was developed. Phase 1 included individual student preparation. An interprofessional telehealth consultation encounter occurred in phase 2 for the error disclosure between the pharmacy and medical students. Phase 3 included faculty-led interprofessional debrief sessions. A pre- and postsimulation survey assessed students' experiences regarding their confidence in error disclosure, use of telehealth technology, and the role of the community pharmacist. Faculty evaluated pharmacy student performance using a 12-point rubric.Results. Presimulation survey responses (n=173) were compared to postsimulation survey responses (n=140). Significant changes were seen for all students' confidence in error disclosure and use of telehealth technology. No significant change was noted in the students' understanding of the community pharmacists' role on the interprofessional team. Pharmacy student performance-based rubric data (n=148) revealed a median score of seven out of 12 for error disclosure and interprofessional communication items.Conclusion. Medical and pharmacy students perceived their confidence improved in interprofessional error disclosure and use of telehealth consultation technology through this interprofessional simulation. Pharmacy students' error disclosure and interprofessional communication skill development were assessed through this simulation.

Atypical teratoid/rhabdoid tumor of the spine

SUMMARY

Atypical teratoid/rhabdoid tumor (AT/RT) is a highly malignant central nervous system neoplasm usually seen in young children and infants. Prognosis for AT/RT is poor, with most patients dying within 1 year of presentation. AT/RT most commonly occurs intracranially. Location in the spine, though previously reported, is rare, and imaging findings have not been emphasized in the past. We present a case of AT/RT occurring in the thoracolumbar spine of a child and review available clinical and imaging findings in previously reported cases of spinal AT/RT.

Learner Success Model in Physical Therapy Education

BACKGROUND AND PURPOSE

Physical therapy educators recognize the need for enhanced learner support to ensure degree completion, licensure, and high-quality, safe patient care. High costs are associated with academic difficulty for learners, educators, programs, institutions, and clinical partners. The urgency to find effective learner support methods is paramount. This paper aims to explain the importance of the affective domain and to highlight external system-level factors affecting learner success through a proposed Learner Success Model in Physical Therapy Education (LSM PTE).

METHOD/MODEL DESCRIPTION AND EVALUATION

The LSM PTE captures the complexity of learner attributes and external systems. This model emphasizes the affective domain and interconnected systems in a socio-ecological model, placing learners within overlapping spheres of influence. The center represents internal attributes and essential learning domains while the spheres represent system-level factors also affecting outcomes. The model's application is explored through a case vignette for a learner needing additional support.

OUTCOMES

Although outcomes of the LSM PTE are not yet known, this model provides a framework for identifying potential impacts within each sphere.

DISCUSSION AND CONCLUSION

The LSM PTE illuminates a comprehensive perspective necessary to support learners in physical therapy education. This approach, which includes the affective domain and various system-level factors, extends beyond cognitive and psychomotor learning domains to promote successful learner outcomes, helping achieve program, profession, and societal goals.

The SPEER: An interprofessional team behavior rubric to optimize geriatric clinical care

Geriatric patients with complex health care needs can benefit from interprofessional (IP) care; however, a major gap in health professional education is determining how to prepare future providers for IP collaboration. Effective IP team behavior assessment tools are needed to teach, implement, and evaluate IP practice skills. After review of IP evaluation tools, the Standardized Patient Encounter Evaluation Rubric (SPEER) was created to evaluate team dynamics in IP practice sites.Independent sample t-tests between faculty and learner SPEER scores showed learners scored themselves 15 points higher than their faculty scores (p < .001). Cronbach's α showed high internal consistency (α = 0.91). Paired t-tests found that learners identified improvements in the team's ability to address the patient's education needs and to allow the patients to voice their expectations. Faculty identified improvements in the teams' ability to make recommendations. Faculty evaluations of learner teams showed improvements in raw ratings on all but two items. Qualitative data analysis for emergent themes showed learners desired team functioning feedback and how teamwork could improve to provide optimal IP care.In conclusion, the SPEER can help faculty and learners identify growth in their teams' ability to perform key IP skills in clinical sites.

Student Outcomes Associated with an Interprofessional Program Incorporating TeamSTEPPS®

BACKGROUND

Interprofessional education (IPE) of health professions students is a starting point for developing collaborative-practice-ready healthcare professionals, ultimately leading to improved patient care. The purpose of this study was to develop and evaluate a novel, foundational, IPE pilot program that incorporates TeamSTEPPS® for health professions students.

METHODS

Students representing 13 different health professions programs participated in successive Level 1 and Level 2 "Foundations of Interprofessional Collaboration: Introduction to TeamSTEPPS®" half-day activities (n = 241). Students' satisfaction with the pilot program, changes in attitudes toward teamwork from before to after participation, TeamSTEPPS® knowledge acquisition, and anticipated future interprofessional collaboration-oriented behavior change were assessed through online surveys.

RESULTS

Overall, students were highly satisfied with the pilot program and reported that learning from other professions was valuable. Statistically significant positive changes were noted in attitudes toward teamwork, most notably with the Level 1 pilot. Greater than 80% of students who completed the surveys demonstrated acquisition of TeamSTEPPS® knowledge. Students also reported feeling more prepared to collaborate interprofessionally in their future practice.

CONCLUSION

This study demonstrated that the two-level foundational pilot program is feasible and had the intended effects with regards to moving health professions students toward becoming collaborative-practice-ready healthcare professionals.