Reduction of Environmental Pollutants and Travel Burden Through an Academic Medical Center-based Electronic Consultation Program

Background: We evaluated the impact of electronic consultation (eConsult) in reducing the environmental pollutants associated with health care delivery. Methods: A retrospective analysis of the eConsult data between July 2018 and December 2022 was extracted from the electronic health record (Epic). Travel time and mileage from the patient home to the academic medical center (AMC) were calculated along with fuel expenditure and greenhouses gas savings. Projected savings through the end of the decade were forecast using a random walk model. Results: A total of 15,499 eConsults were submitted to AMC specialist providers from community primary care providers. Completed eConsults (n = 11,590) eliminated the need for a face-to-face visit with a specialist provider, eliminating mileage, fuel, time, and pollutants associated with face to face visits. In-state travel distance saved was 310,858 miles, travel time saved was 5,491 h, with an associated fuel reduction of 13,575 gallons and $56,893 savings. This reduced greenhouse gas emissions by 128 metric tons of carbon dioxide, 0.022 tons of nitrogen oxide, 0.005 tons of methane, and 0.001 tons of nitrous oxide. Out of state travel distance saved was 188,346 miles with 2,842 h reduced travel time, and associated fuel reduction of 8,225 gallons and of $34,118. Reduced greenhouse gas emissions were equivalent to 77 metric tons of carbon dioxide, 0.0132 tons of nitrogen oxide, 0.0033 tons of methane, and 0.0007 tons of nitrous oxide. Conclusion: This study indicates that medical care provided through telehealth modalities reduces the environmental impact of pollutants associated with face to face visits.

Communicating Patient Discharge Readiness: An Implementation Evaluation in an Inpatient Hospital Medicine Setting

BACKGROUND

The progression of patients through a hospital from admission to discharge can be slowed by delays in patient discharge, increasing pressure on health care staff. We designed and piloted the Discharge Today tool, with the goal of improving the efficiency of patient discharge; however, adoption remained low.

PURPOSE

To close this implementation gap, we deployed and evaluated a 4-part implementation strategy bundle.

METHODS

We measured the success of implementation by evaluating validated implementation outcomes using both quantitative and qualitative methods, grounded in Normalization Process Theory.

RESULTS

The implementation strategies used were effective for increasing use of the Discharge Today tool by hospital medicine physicians and advanced practice providers during both the active and passive implementation periods.

CONCLUSIONS

While the implementation strategies used were effective, qualitative findings indicate that limitations in the functionality of the tool, alongside inconsistent use of the tool across clinical staff, continued to inhibit adoption.

Harnessing technology to improve sleep in frontline healthcare workers: A pilot study of electronic noise-masking earbuds on subjective and objective sleep measures

Objective: This pilot study assessed the effects of electronic noise-masking earbuds on subjective sleep perception and objective sleep parameters among healthcare workers (HCWs) reporting sleep difficulties during the COVID-19 pandemic. Methods: Using a pre-post design, 77 HCWs underwent 3 nights of baseline assessment followed by a 7-night intervention period. Participants wore an at-home sleep monitoring headband to assess objective sleep measures and completed subjective self-report assessments. The difference in mean sleep measures from baseline to intervention was estimated in linear mixed models. Results: Compared to baseline assessments, HCWs reported significant improvements in sleep quality as measured by the Insomnia Severity Index (ISI) (Cohen's d = 1.74, p < 0.001) and a significant reduction in perceived sleep onset latency (SOL) during the intervention (M = 17.2 minutes, SD = 7.7) compared to baseline (M = 24.7 minutes, SD = 16.1), (Cohen's d = -0.42, p = 0.001). There were no significant changes in objective SOL (p = 0.703). However, there was a significant interaction between baseline objective SOL (<20 minutes vs >20 minutes) and condition (baseline vs intervention) (p = 0.002), such that individuals with objective SOL >20 minutes experienced a significant decrease in objective SOL during the intervention period compared to baseline (p = 0.015). Conclusions: HCWs experienced a significant improvement in perceived SOL and ISI scores after using the electronic noise-masking earbuds. Our data provide preliminary evidence for a nonpharmacological intervention to improve the sleep quality of HCWs which should be confirmed by future controlled studies.

Visualizing moiré ferroelectricity via plasmons and nano-photocurrent in graphene/twisted-WSe2 structures

Ferroelectricity, a spontaneous and reversible electric polarization, is found in certain classes of van der Waals (vdW) materials. The discovery of ferroelectricity in twisted vdW layers provides new opportunities to engineer spatially dependent electric and optical properties associated with the configuration of moiré superlattice domains and the network of domain walls. Here, we employ near-field infrared nano-imaging and nano-photocurrent measurements to study ferroelectricity in minimally twisted WSe2. The ferroelectric domains are visualized through the imaging of the plasmonic response in a graphene monolayer adjacent to the moiré WSe2 bilayers. Specifically, we find that the ferroelectric polarization in moiré domains is imprinted on the plasmonic response of the graphene. Complementary nano-photocurrent measurements demonstrate that the optoelectronic properties of graphene are also modulated by the proximal ferroelectric domains. Our approach represents an alternative strategy for studying moiré ferroelectricity at native length scales and opens promising prospects for (opto)electronic devices.

Negative refraction in hyperbolic hetero-bicrystals

We visualized negative refraction of phonon polaritons, which occurs at the interface between two natural crystals. The polaritons-hybrids of infrared photons and lattice vibrations-form collimated rays that display negative refraction when passing through a planar interface between the two hyperbolic van der Waals materials: molybdenum oxide (MoO₃) and isotopically pure hexagonal boron nitride (h¹¹BN). At a special frequency ω₀, these rays can circulate along closed diamond-shaped trajectories. We have shown that polariton eigenmodes display regions of both positive and negative dispersion interrupted by multiple gaps that result from polaritonic-level repulsion and strong coupling.

Mother's Milk Messaging™: trial evaluation of app and texting for breastfeeding support

BACKGROUND

New mothers experience BF challenges but have limited evidence-based technology-enabled support.

OBJECTIVES

1) Determine if using the Mother's Milk Messaging™ app improved aspects of breastfeeding and breastfeeding rates and 2) Describe engagement as well as themes from the qualitative feedback on the app.

METHOD

Randomized Controlled Trial National sample of primiparous, singleton mothers recruited online and then randomized using stratification by language into three arms: 1) BF text messages plus app; 2) BF text messages, app and physician-moderated private Facebook (FB) group; 3) Attention control group who received injury prevention texts. Exclusive breastfeeding rates as primary outcome and knowledge/attitude, confidence, and social support as secondary outcomes. We determined engagement through analysis of app usage metrics. We conducted and content-coded interviews with participants to learn more about app usage and BF experience. Due to the nature of the intervention participants could not be blinded.

RESULTS

There were a total of 346 participants in the trial, with 227 in the Intervention (n = 154 group 1 and n = 156 group 2) and 119 in the control group. Because of minimal Facebook activity, the two intervention groups 1 and 2 were combined. There were no differences in breastfeeding exclusivity and duration. (NS). Women in the intervention arm reported significantly higher confidence with breastfeeding and perceived social support to the control group (p < .05). Greater than 80% registered the app and those that engaged with the app had higher scores with time. Mothers appreciated receiving text messages and videos with reliable information. No harm was reported in this study.

CONCLUSION

MMM increased confidence with breastfeeding and with gathering social supports. Exclusively BF was high in all participants. Mothers perceived it as useful and dependable especially the texting.

Assessment of a Mobile Health iPhone App for Semiautomated Self-management of Chronic Recurrent Medical Conditions Using an N-of-1 Trial Framework: Feasibility Pilot Study

BACKGROUND

Management of chronic recurrent medical conditions (CRMCs), such as migraine headaches, chronic pain, and anxiety/depression, remains a major challenge for modern providers. Our team has developed an edge-based, semiautomated mobile health (mHealth) technology called iMTracker that employs the N-of-1 trial approach to allow self-management of CRMCs.

OBJECTIVE

This study examines the patterns of adoption, identifies CRMCs that users selected for self-application, and explores barriers to use of the iMTracker app.

METHODS

This is a feasibility pilot study with internet-based recruitment that ran from May 15, 2019, to December 23, 2020. We recruited 180 patients to pilot test the iMTracker app for user-selected CRMCs for a 3-month period. Patients were administered surveys before and after the study.

RESULTS

We found reasonable usage rates: a total of 73/103 (70.9%) patients who were not lost to follow-up reported the full 3-month use of the app. Most users chose to use the iMTracker app to self-manage chronic pain (other than headaches; 80/212, 37.7%), followed by headaches in 36/212 (17.0%) and mental health (anxiety and depression) in 27/212 (12.8%). The recurrence rate of CRMCs was at least weekly in over 93% (169/180) of patients, with 36.1% (65/180) of CRMCs recurring multiple times in a day, 41.7% (75/180) daily, and 16.1% (29/180) weekly. We found that the main barriers to use were the design and technical function of the app, but that use of the app resulted in an improvement in confidence in the efficiency and safety/privacy of this approach.

CONCLUSIONS

The iMTracker app provides a feasible platform for the N-of-1 trial approach to self-management of CRMCs, although internet-based recruitment provided limited follow-up, suggesting that in-person evaluation may be needed. The rate of CRMC recurrence was high enough to allow the N-of-1 trial assessment for most traits.

Nano-spectroscopy of excitons in atomically thin transition metal dichalcogenides

Excitons play a dominant role in the optoelectronic properties of atomically thin van der Waals (vdW) semiconductors. These excitons are amenable to on-demand engineering with diverse control knobs, including dielectric screening, interlayer hybridization, and moiré potentials. However, external stimuli frequently yield heterogeneous excitonic responses at the nano- and meso-scales, making their spatial characterization with conventional diffraction-limited optics a formidable task. Here, we use a scattering-type scanning near-field optical microscope (s-SNOM) to acquire exciton spectra in atomically thin transition metal dichalcogenide microcrystals with previously unattainable 20 nm resolution. Our nano-optical data revealed material- and stacking-dependent exciton spectra of MoSe2, WSe2, and their heterostructures. Furthermore, we extracted the complex dielectric function of these prototypical vdW semiconductors. s-SNOM hyperspectral images uncovered how the dielectric screening modifies excitons at length scales as short as few nanometers. This work paves the way towards understanding and manipulation of excitons in atomically thin layers at the nanoscale.

A Pilot Study and Ecological Model of Smoking Cues to Inform Mobile Health Strategies for Quitting Among Low-Income Smokers

One crucial factor that leads to disparities in smoking cessation between groups with higher and lower socioeconomic status is more prevalent socioenvironmental smoking cues in low-income communities. Little is known about how these cues influence socioeconomically disadvantaged smokers in real-world scenarios and how to design interventions, especially mobile phone-based interventions, to counteract the impacts of various types of smoking cues. We interviewed 15 current smokers living in low-income communities and scanned their neighborhoods to explore smoking-related experiences and identify multilevel cues that may trigger them to smoke. Findings suggest four major types of smoking cues influence low-income smokers-internal, habitual, social, and environmental. We propose an ecological model of smoking cues to inform the design of mobile health (mHealth) interventions for smoking cessation. We suggest that user-triggered strategies will be most useful to address internal cues; server-triggered strategies will be most suitable in changing perceived social norms of smoking and routine smoking activities to address social and habitual cues; and context-triggered strategies will be most effective for counteracting environmental cues. The pros and cons of each approach are discussed regarding their cost-effectiveness, the potential to provide personalized assistance, and scale.

Nanoscale lattice dynamics in hexagonal boron nitride moiré superlattices

Twisted two-dimensional van der Waals (vdW) heterostructures have unlocked a new means for manipulating the properties of quantum materials. The resulting mesoscopic moiré superlattices are accessible to a wide variety of scanning probes. To date, spatially-resolved techniques have prioritized electronic structure visualization, with lattice response experiments only in their infancy. Here, we therefore investigate lattice dynamics in twisted layers of hexagonal boron nitride (hBN), formed by a minute twist angle between two hBN monolayers assembled on a graphite substrate. Nano-infrared (nano-IR) spectroscopy reveals systematic variations of the in-plane optical phonon frequencies amongst the triangular domains and domain walls in the hBN moiré superlattices. Our first-principles calculations unveil a local and stacking-dependent interaction with the underlying graphite, prompting symmetry-breaking between the otherwise identical neighboring moiré domains of twisted hBN.

Here, the authors investigate the lattice dynamics of twisted hexagonal boron nitride layers via nano-infrared spectroscopy, showing local and stacking-dependent variations of the optical phonon frequencies associated to the interaction with the graphite substrate.

Building MedVenture - A mobile health application to improve adolescent medication adherence - Using a multidisciplinary approach and academic-industry collaboration

Objective

Mobile health (mHealth) tools are increasingly used to support medication adherence yet few have been designed specifically for the pediatric population. This paper describes the development of a medication adherence application (MedVenture) using the integration of patient and healthcare provider input, health behavior theory, and user engagement strategies for adolescents with chronic gastrointestinal disease.

Methods

MedVenture was created by a multidisciplinary research team consisting of a gastroenterologist, a social health psychologist, software developers, and digital health researchers. Healthcare providers and adolescent patients were interviewed to identify barriers to medication adherence, explore ways that technologies could best support medication adherence for both patients and providers, and determine user requirements and core design features for a digital health tool. Intervention mapping was used to match themes from qualitative content analysis to known efficacious adherence strategies, according to a conceptual framework based on self-determination theory. Iterative design with review by the research team and two rounds of user testing informed the final prototype.

Results

Three themes were identified from content analysis: 1) lack of routine contributes to nonadherence, 2) adolescents sometimes purposefully forgo medications, and 3) healthcare providers would prefer a tool that promotes patient self-management rather than one that involves patient-provider interaction. These findings, combined with evidence-based adherence and user engagement strategies, resulted in the development of MedVenture – a game-based application to improve planning and habit formation.

Conclusions

Academic-industry collaboration incorporating stakeholders can facilitate the development of mobile health tools designed specifically for adolescents with chronic disease.

Development and Implementation of a Multidisciplinary Electronic Discharge Readiness Tool: User-Centered Design Approach

BACKGROUND

Typical solutions for improving discharge planning often rely on one-way communication mechanisms, static data entry into the electronic health record (EHR), or in-person meetings. Lack of timely and effective communication can adversely affect patients and their care teams.

OBJECTIVE

Applying robust user-centered design strategies, we aimed to design an innovative EHR-based discharge readiness communication tool (the Discharge Today tool) to enable care teams to communicate any barriers to discharge, the status of patient discharge readiness, and patient discharge needs in real time across hospital settings.

METHODS

We employed multiple user-centered design strategies, including exploration of the current state for documenting discharge readiness and directing discharge planning, iterative low-fidelity prototypes, multidisciplinary stakeholder meetings, a brainwriting premortem exercise, and preproduction user testing. We iteratively collected feedback from users via meetings and surveys.

RESULTS

We conducted 28 meetings with 20 different stakeholder groups. From these stakeholder meetings, we developed 14 low-fidelity prototypes prior to deploying the Discharge Today tool for our pilot study. During the pilot study, stakeholders requested 46 modifications, of which 25 (54%) were successfully executed. We found that most providers who responded to the survey reported that the tool either saved time or did not change the amount of time required to complete their discharge workflow (21/24, 88%). Responses to open-ended questions offered both positive feedback and opportunities for improvement in the domains of efficiency, integration into workflow, avoidance of redundancies, expedited communication, and patient-centeredness.

CONCLUSIONS

Survey data suggest that this electronic discharge readiness tool has been successfully adopted by providers and clinical staff. Frequent stakeholder engagement and iterative user-centered design were critical to the successful implementation of this tool.

Benefits, Facilitators, and Recommendations for Digital Health Academic-Industry Collaboration: A Mini Review

Digital health remains a growing and challenging niche in public health practice. Academic-industry collaboration (AIC) offers a mechanism to bring disparate sectors together to alleviate digital health challenges of engagement, reach, sustainability, dissemination, evaluation, and equity. Despite the ongoing endorsements for AIC in digital health, limited understanding exists of successful AIC exists. Most published research highlights the barriers of collaboration rather than efficacy, leaving collaborators asking: What are the benefits and facilitators of AIC and do they apply in digital health? As an initial effort to fill the gap in the literature, the purpose of this mini review outlines the benefits and facilitators from previous AIC and offers recommendations specific to digital health.

"It depends:" a qualitative study on digital health academic-industry collaboration

BACKGROUND

Academic-industry collaborations (AICs) are endorsed to alleviate challenges in digital health, but partnership experiences remain understudied. The qualitative study's objective investigated collaboration experiences between academic institutions and digital health companies.

METHODS

A phenomenology methodology captured experiences of AICs, eliciting perspectives from academic researchers and industry affiliates (e.g., leadership, company investigators). Semi-structured interviews probed eligible collaborators about their experiences in digital health. Analysts coded and organized data into significant statements reaching thematic saturation.

RESULTS

Participants (N=20) were interviewed from 6 academic institutions and 14 unique industry partners. Seven themes emerged: (I) Collaboration evolves with time, relationships, funding, and evidence; (II) Collaboration demands strong relationships and interpersonal dynamics; (III) Operational processes vary across collaborations; (IV) Collaboration climate and context matters; (V) Shared expectations lead to a better understanding of success; (VI) Overcoming challenges with recommendations; (VII) Collaboration may help navigate the global pandemic.

CONCLUSIONS

Digital health academic industry collaboration demands strong relationships, requiring flexible mechanisms of collaboration and cultural fit. Diverse models of collaboration exist and remain dependent on contextual factors. While no collaboration conquers all challenges in digital health, AICs may serve as a facilitator for improved digital health products, thus advancing science, promoting public health, and benefiting the economy.

Using Telehealth for Hospice Reauthorization Visits: Results of a Quality Improvement Analysis

BACKGROUND

Increasing hospice need, a growing shortage of hospice providers, and concerns about in-person services because of coronavirus disease 2019 (COVID-19) require hospices to innovate care delivery.

MEASURES

This project compared outcomes between hospice reauthorization visits conducted via telehealth and in person. After each visit, providers, patients, and caregivers completed telehealth acceptance surveys, and providers recorded reauthorization recommendations.

INTERVENTION

Providers conducted 88 concurrent in-person and telehealth visits between June and November 2019.

OUTCOMES

No statistically significant differences in reauthorization recommendations were found between telehealth and in-person visits. Satisfaction with telehealth was high; 88% of patients/caregivers and 78% of providers found telehealth services as effective as in-person visits.

CONCLUSIONS/LESSONS LEARNED

Results indicate that telehealth can successfully support clinical decision making for hospice reauthorization. These findings show telehealth to be reliable and acceptable for certain types of hospice care even before COVID-19, which emphasizes its importance both during and after the current public health emergency.

What Do Patients Want? A Qualitative Analysis of Patient, Provider, and Administrative Perceptions and Expectations About Patients' Hospital Stays

Patient experience is increasingly recognized as a measure of health care quality and patient-centered care and is currently measured through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The HCAHPS survey may miss key factors important to patients, and in particular, to underserved patient populations. We performed a qualitative study utilizing semi-structured interviews with 45 hospitalized English- and Spanish-speaking patients and 6 focus groups with physicians, nurses, and administrators at a large, urban safety-net hospital. Four main themes were important to patients: (1) the hospital environment including cleanliness and how hospital policies and procedures impact patients’ perceived autonomy, (2) whole-person care, (3) communication with and between care teams and utilizing words that patients can understand, and (4) responsiveness and attentiveness to needs. We found that several key themes that were important to patients are not fully addressed in the HCAHPS survey and there is a disconnect between what patients and care teams believe patients want and what hospital policies drive in the care environment.

Elements of Social Convoy Theory in Mobile Health for Palliative Care: Scoping Review

BACKGROUND

Mobile health (mHealth) provides a unique modality for improving access to and awareness of palliative care among patients, families, and caregivers from diverse backgrounds. Some mHealth palliative care apps exist, both commercially available and established by academic researchers. However, the elements of family support and family caregiving tools offered by these early apps is unknown.

OBJECTIVE

The objective of this scoping review was to use social convoy theory to describe the inclusion and functionality of family, social relationships, and caregivers in palliative care mobile apps.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review guidelines, a systematic search of palliative care mHealth included (1) research-based mobile apps identified from academic searches published between January 1, 2010, and March 31, 2019 and (2) commercially available apps for app stores in April 2019. Two reviewers independently assessed abstracts, app titles, and descriptions against the inclusion and exclusion criteria. Abstracted data covered app name, research team or developer, palliative care element, target audience, and features for family support and caregiving functionality as defined by social convoy theory.

RESULTS

Overall, 10 articles describing 9 individual research-based apps and 22 commercially available apps were identified. Commercially available apps were most commonly designed for both patients and social convoys, whereas the majority of research apps were designed for patient use only.

CONCLUSIONS

Results suggest there is an emerging presence of apps for patients and social convoys receiving palliative care; however, there are many needs for developers and researchers to address in the future. Although palliative care mHealth is a growing field, additional research is needed for apps that embrace a team approach to information sharing, target family- and caregiver-specific issues, promote access to palliative care, and are comprehensive of palliative needs.

Flash glucose monitoring: Impact on markers of glycaemic control and patient-reported outcomes in individuals with type 1 diabetes mellitus in the real-world setting

AIMS

We aimed to evaluate both glycaemic parameters and patient-reported outcomes in patients prescribed FGM based on the local criteria at our institution.

METHODS

This retrospective observational study included patients aged > 18 years with a diagnosis of type 1 diabetes mellitus (T1DM) who were prescribed FreeStyle Libre FGM (n = 90). Quantitative data on glycaemic parameters was collected pre- and post-initiation of FGM in addition to patient-reported outcome measures (PROMs). The primary outcome was change in pre- and post-FGM levels of glycosylated haemoglobin (HbA1C).

RESULTS

There was a mean reduction in HbA_1c of -7.29 ± 10.76 mmol/mol (p < 0.001, CI_95% 4.94-9.64) sustained to the latest reading. There was also a mean reduction in the number of hypoglycaemic episodes per week of 3.20 (percentage reduction 51.86%, p < 0.001, CI_95% 1.64-4.77). A significant improvement in quality of life scores was noted in all five domains of the abbreviated DDS between before and after starting FGM (p < 0.001). Key themes highlighted in inductive content analysis include 'life-changing', 'positive experience', and 'convenient'.

CONCLUSION

Flash glucose monitoring is associated with significant improvement in HbA_1c to a mean follow-up of 4.6 months. Additionally, patients reported positive experiences of FGM with significant improvement in all aspects of a focussed Diabetes Distress Scale.

Advancing evidence-based digital health through an innovative research environment: an academic-industry collaboration case report

The proliferation of technology enthuses clinicians, researchers, and entrepreneurs to revolutionize health care and care delivery. Intersecting in the field of digital health, academic-industry collaboration (AIC) play a critical role in advancing evidence-based innovations into real world application. AIC models vary, but historically have not included the strong emphasis on rapid research and discovery that the digital health field demands. Due to the voluminous availability of real time patient and client data, academic health centers offer a rich interdisciplinary environment to develop, pilot and evaluate innovations in pragmatic settings. Despite the opportunity between academic health centers and industry to advance digital health innovation through rapid research, limited evidence exists of such collaboration. The purpose of this case report is to examine an AIC facilitating research of new health technologies within an academic health center. This paper presents a case report involving collaboration between diverse technology industry partners and an academic health center that encompasses a university health system (UCHealth), a university technology transfer office (CU Innovations), an innovation center (CARE Innovation Center), and research collaborators (mHealth Impact Laboratory). Case assertions discuss the lessons learned and recommendations when implementing such collaboration in practice. The principal finding is that academic health centers offer an innovative environment for AIC in digital health. Collaborations between academia and industry provide much promise in ensuring health innovations are scientifically sound while meeting the needs of a rapidly evolving technical climate.

Appointment reminders by text message in a safety net health care system: a pragmatic investigation

INTRODUCTION

Short Message Service (SMS) appointment reminders may provide a wide-reaching, low cost approach to reducing operational inefficiencies and improving access to care. Previous studies indicate this modality may improve attendance rates, yet there is a need for large-scale, pragmatic studies that include unintended consequences and operational costs.

METHODS

This pragmatic investigation was a before-after analysis that compared visit attendance outcomes among patients who opted into SMS appointment reminders with outcomes among those who declined over an 18-month evaluation period from March 25, 2013, to September 30, 2014. Eligibility in our integrated safety net health care system included age greater than 17, English or Spanish as a primary language, and a cell phone number in our scheduling system.

RESULTS

47,390 patients were invited by SMS to participate, of which 20,724 (43.7 percent) responded with 18,138 opting in (81.5 percent of respondents). Participants received SMS reminders for 77,783 scheduled visits; comparison group patients (N=72,757) were scheduled for 573,079 visits during the evaluation period. Intervention and comparison groups had, respectively, attendance rates of 72.8 percent versus 66.1 percent (p<0.001), cancellation rates of 13.2 percent versus 18.6 percent (p<0.001), and no show rates of 14.0 percent versus 15.3 percent. Patient satisfaction with text messaging ranged from 77 percent to 96 percent. Implementation challenges included a low rate of inaccurate reminders due to non-standard use of the scheduling system across clinical departments.

DISCUSSION

SMS appointment reminders improve patient satisfaction and provide a low operating cost approach to reducing operational inefficiencies through improved attendance rates in an integrated safety net health care system.

Text Message Support for Weight Loss in Patients With Prediabetes: A Randomized Clinical Trial

OBJECTIVE

Although the benefits of in-person Diabetes Prevention Program (DPP) classes for diabetes prevention have been demonstrated in trials, effectiveness in clinical practice is limited by low participation rates. This study explores whether text message support enhances weight loss in patients offered DPP classes.

RESEARCH DESIGN AND METHODS

English- and Spanish-speaking patients with prediabetes (n = 163) were randomized to the control group, which only received an invitation to DPP classes as defined by the Centers for Disease Control and Prevention, or to the text message-augmented intervention group, which also received text messages adapted from the DPP curriculum for 12 months.

RESULTS

Mean weight decreased 0.6 pounds (95% CI -2.7 to 1.6) in the control group and 2.6 pounds (95% CI -5.5 to 0.2) in the intervention group (P value 0.05). Three percent weight loss was achieved by 21.5% of participants in the control group (95% CI 12.5-30.6), compared with 38.5% in the intervention group (95% CI 27.7-49.3) (absolute difference 17.0%; P value 0.02). Mean glycated hemoglobin (HbA1c) increased by 0.19% or 2.1 mmol/mol (95% CI -0.1 to 0.5%) and decreased by 0.09% or 1.0 mmol/mol (95% CI -0.2 to 0.0%) in the control group and intervention participants, respectively (absolute difference 0.28%; P value 0.07). Stratification by language demonstrated a significant treatment effect in Spanish speakers but not in English speakers.

CONCLUSIONS

Text message support can lead to clinically significant weight loss in patients with prediabetes. Further study assessing effect by primary language and in an operational setting is warranted.

Using antibiograms to improve antibiotic prescribing in skilled nursing facilities

BACKGROUND

Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown.

OBJECTIVE

To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing.

DESIGN AND SETTING

Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs.

METHODS

Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities.

RESULTS

We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant ([Formula: see text]).

CONCLUSIONS

Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.

Translating Health Services Research into Practice in the Safety Net

OBJECTIVE

To summarize research relating to health services research translation in the safety net through analysis of the literature and case study of a safety net system.

DATA SOURCES/STUDY SETTING

Literature review and key informant interviews at an integrated safety net hospital.

STUDY DESIGN

This paper describes the results of a comprehensive literature review of translational science literature as applied to health care paired with qualitative analysis of five key informant interviews conducted with senior-level management at Denver Health and Hospital Authority.

PRINCIPAL FINDINGS

Results from the literature suggest that implementing innovation may be more difficult in the safety net due to multiple factors, including financial and organizational constraints. Results from key informant interviews confirmed the reality of financial barriers to innovation implementation but also implied that factors, including institutional respect for data, organizational attitudes, and leadership support, could compensate for disadvantages.

CONCLUSIONS

Translating research into practice is of critical importance to safety net providers, which are under increased pressure to improve patient care and satisfaction. Results suggest that translational research done in the safety net can better illuminate the special challenges of this setting; more such research is needed.

A mobile health infrastructure to support underserved patients with chronic disease

BACKGROUND

Chronic diseases are the global leading cause of death, but the US health system is poorly designed to support patients with chronic disease. Underserved patients report high rates of cell phone use and interest in using mobile technology for health care. A mobile health infrastructure may help transform health care delivery for underserved patients with chronic disease.

PROBLEM

This study assessed the feasibility of integrating mobile health infrastructure with clinical information systems and the electronic medical record (EMR) to support patients with chronic disease through automated, bidirectional text messaging.

GOALS

Three priority areas of chronic disease management were targeted. Existing self-management support was expanded, and new support for laboratory test scheduling and medication management was created.

STRATEGY

Adult patients (n=135) with diabetes selected preferred content and scheduling for self-management message prompts. Outreach messages were sent to patients overdue for laboratory tests and medications. Manual review of pharmacy and laboratory outreach data was conducted for quality assurance. Focus groups were held to solicit patient perspectives.

RESULTS

Patients sent over 6500 response messages with response rates of 53.7% (blood sugar), 48.8% (step counts), and 31.9% (blood pressure). Laboratory data integration was achieved, but pharmacy data gaps required ongoing manual review. Focus group participants reported improved self-management and information awareness.

IMPLICATIONS

HIT was used to address dependency on visit-bound disease management in a novel, low-cost way. Use of a mobile health infrastructure was feasible. Text messaging solutions may mitigate barriers to access and enhance support for patients with chronic disease.

Care by cell phone: text messaging for chronic disease management

OBJECTIVES

To assess the feasibility of engaging adults with diabetes in self management behaviors between clinic visits by using cell phone text messaging to provide blood sugar measurement prompts and appointment reminders.

STUDY DESIGN

Quasi-experimental pilot among adult diabetic patients with cell phones who receive regular care at a federally qualified community health center in Denver, Colorado, which serves a population that is predominantly either uninsured (41%) or on Medicaid or Medicare (56%).

METHODS

Patients (N = 47) received text message prompts over a 3-month period. Blood sugar readings were requested 3 times per week (Monday, Wednesday, and Friday). Reminders were sent 7, 3, and 1 day(s) before each scheduled appointment. Acknowledgments were returned for all patient-sent messages. Focus groups were conducted in English and Spanish with selected patients (n = 8).

RESULTS

Patients of all ages were active participants. Correctly formatted responses were received for 67.3% of 1585 prompts. More than three-fourths (79%) of the cohort responded to more than 50% of their prompts. The appointment analysis was underpowered to detect significant changes in attendance. Participants reported increased social support, feelings that the program "made them accountable," and increased awareness of health information. Two-thirds (66%) of patients provided glucose readings when prompted during the study, compared with 12% at 2 preceding clinic visits.

CONCLUSIONS

For certain patients, cell phone-based text messaging may enhance chronic disease management support and patient-provider communications beyond the clinic setting.

Nurse-run, telephone-based outreach to improve lipids in people with diabetes

BACKGROUND

There is a need for randomized, prospective trials of case management interventions with resource utilization analyses.

OBJECTIVES

To determine whether algorithm-driven telephone care by nurses improves lipid control in patients with diabetes.

DESIGN

Prospective, randomized, controlled trial.

PARTICIPANTS

Adults with diabetes at a federally funded community health center were randomly assigned to intervention (n = 381) or usual-care (n = 381) groups.

INTERVENTIONS

Nurses independently initiated and titrated lipid therapy and promoted behavioral change through motivational interviewing and self-management techniques. Other parameters of diabetes care were addressed based on time constraints.

MAIN MEASURES

The primary outcome was the proportion of patients with a low-density lipoprotein (LDL) less than 100 mg/dL. Secondary outcomes included the number of hospital admissions, total hospital charges per patient, and the proportion of patients meeting other lipid, glycemic, and blood pressure guidelines.

KEY RESULTS

The percent of patients with an LDL < 100 mg/dL increased from 52.0% to 58.5% in the intervention group and decreased from 55.6% to 46.7% in the control group (P < .01). Average cost per patient to the healthcare system was less for the intervention group ($6600 vs $9033, P = .03). Intervention patients trended toward fewer hospital admissions (P = .06). The intervention did not affect glycemic and blood pressure outcomes.

CONCLUSIONS

Nurses can improve lipid control in patients with diabetes in a primarily indigent population through telephone care using moderately complex algorithms, but a more targeted approach is warranted. Telephone-based outreach may decrease resource utilization, but more study is needed.

A GIS-based methodology for selecting stormwater disconnection opportunities

The purpose of this paper is to introduce a geographic information system (GIS)-based decision support tool that assists the user to select not only areas where (retrofit) sustainable drainage systems (SuDS) could be implemented within a large catchment (>100 ha), but also to allow discrimination between suitable SuDS techniques based on their likely feasibility and effectiveness. The tool is applied to a case study catchment within London, UK, with the aim of increasing receiving water quality by reducing combined sewer overflow (CSO) spill frequency and volume. The key benefit of the tool presented is to allow rapid assessment of the retrofit SuDS potential of large catchments. It is not intended to replace detailed site investigations, but may help to direct attention to sites that have the greatest potential for retrofit SuDS implementation. Preliminary InfoWorks CS modelling of 'global disconnections' within the case study catchment, e.g. the removal of 50% of the total impervious area, showed that CSO spill volume could be reduced by 55 to 78% during a typical year. Using the disconnection hierarchy developed by the authors, the feasibility of retrofit SuDS deployment within the case study catchment is assessed, and the implications discussed.

The impact of tailored diabetes registry report cards on measures of disease control: a nested randomized trial

BACKGROUND

Most studies of diabetes self-management that show improved clinical outcome performance involve multiple, time-intensive educational sessions in a group format. Most provider performance feedback interventions do not improve intermediate outcomes, yet lack targeted, patient-level feedback.

METHODS

5,457 low-income adults with diabetes at eight federally-qualified community health centers participated in this nested randomized trial. Half of the patients received report card mailings quarterly; patients at 4 of 8 clinics received report cards at every clinic visit; and providers at 4 of 8 clinics received quarterly performance feedback with targeted patient-level data. Expert-recommended glycemic, lipid, and blood pressure outcomes were assessed. Assessment of report card utility and patient and provider satisfaction was conducted through mailed patient surveys and mid- and post-intervention provider interviews.

RESULTS

Many providers and the majority of patients perceived the patient report card as being an effective tool. However, patient report card mailings did not improve process outcomes, nor did point-of-care distribution improve intermediate outcomes. Clinics with patient-level provider performance feedback achieved a greater absolute increase in the percentage of patients at target for glycemic control compared to control clinics (6.4% vs 3.8% respectively, Generalized estimating equations Standard Error 0.014, p < 0.001, CI -0.131 - -0.077). Provider reaction to performance feedback was mixed, with some citing frustration with the lack of both time and ancillary resources.

CONCLUSIONS

Patient performance report cards were generally well received by patients and providers, but were not associated with improved outcomes. Targeted, patient-level feedback to providers improved glycemic performance. Provider frustration highlights the need to supplement provider outreach efforts.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00827710.

Changes in insurance status and access to care in an integrated safety net healthcare system

This paper focuses on a cohort of uninsured patients that have accessed outpatient healthcare services in an urban safety net, evaluating the degree to which they switch insurance status and the impact this switching has on access to care. The results indicate that in an integrated safety net system, there is a high frequency of insurance status switching by the uninsured. Uninsured patients who switch to insured status were found to be more likely to visit specialty points of care and less likely to visit urgent points of care than the continuously uninsured. It is well documented that insurance coverage and continuity of care influence health status. Continuity of insurance coverage also has an impact on access to care for those receiving services within a safety net healthcare system.

Bronchiolitis Obliterans Organizing Pneumonia: A Late Complication of Stem Cell Transplantation

Bronchiolitis obliterans organizing pneumonia (BOOP) is a late complication of hematopoietic stem cell transplantation. Many transplant recipients have returned to their community oncologists before BOOP has occurred. The etiology of BOOP in transplant recipients is not understood fully, but it may be associated with chronic graft-versus-host disease. BOOP presents both vague and common symptoms that can progress into respiratory failure but respond to early and appropriate treatment. Early recognition and treatment of BOOP are essential to improving survival of patients who are post-transplantation. Community oncology nurses are in a key position to support initiation of side-effect management. This article presents information about the etiology, presentation, diagnostic testing, and treatment of BOOP. Two case studies are included that illustrate the typical course of BOOP and its treatment.

Alcohol ethoxylates mediate their bacteriostatic effect by altering the cell membrane of Escherichia coli NCTC 8196

The minimum inhibitory concentration (MIC) of a homologous series of alcohol ethoxylates with the same head group size (E6) but differing in the number of carbon atoms in their 'tail group' from 10 to 16 was determined for Staphylococcus aureus NCTC 4163 and Escherichia coli NCTC 8196 using a turbidimetric assay. All the surfactants tested demonstrated bacteriostatic activity against both organisms. A tetrazolium assay showed that C14E6 and C16E6 had little effect on the membrane-bound dehydrogenase enzyme activity of E. coli NCTC 8196 compared with C10E6 and C12E6. C10E6 caused leakage both of K(+) and nucleotides in a concentration-dependent manner above its MIC of 0.2 mM. C12E6 caused some leakage at concentrations below its MIC (0.12 mM).

Hope makes a difference

Hope. It is a word that is often used but one which we do not stop to think intentionally about. It may be difficult to define, and frequently many come to know it more by its absence. Nurses espouse the value of hope, but it is a concept that often seems elusive when one is trying to put it into practice. The author suggests that hope is at the heart of psychiatric nursing practice and provides insights and reflections about how it has made a difference in the lives of individuals.

A comparison of neustonic plastic and zooplankton at different depths near the southern California shore

Previous studies of neustonic debris have been limited to surface sampling. Here we conducted two trawl surveys, one before and one shortly after a rain event, in which debris and zooplankton density were measured at three depths in Santa Monica Bay, California. Surface samples were collected with a manta trawl, mid-depth samples with a bongo net and bottom samples with an epibenthic sled, all having 333 micron nets. Density of debris was greatest near the bottom, least in midwater. Debris density increased after the storm, particularly at the sampling site closest to shore, reflecting inputs from land-based runoff and resuspended matter. The mass of plastic collected exceeded that of zooplankton, though when the comparison was limited to plastic debris similar to the size of most zooplankton, zooplankton mass was three times that of debris.

A comparison of neustonic plastic and zooplankton abundance in southern California's coastal waters

The density of neustonic plastic particles was compared to that of zooplankton in the coastal ocean near Long Beach, California. Two trawl surveys were conducted, one after an extended dry period when there was little land-based runoff, the second shortly after a storm when runoff was extensive. On each survey, neuston samples were collected at five sites along a transect parallel to shore using a manta trawl lined with 333 micro mesh. Average plastic density during the study was 8 pieces per cubic meter, though density after the storm was seven times that prior to the storm. The mass of plastics was also higher after the storm, though the storm effect on mass was less than it was for density, reflecting a smaller average size of plastic particles after the storm. The average mass of plastic was two and a half times greater than that of plankton, and even greater after the storm. The spatial pattern of the ratio also differed before and after a storm. Before the storm, greatest plastic to plankton ratios were observed at two stations closest to shore, whereas after the storm these had the lowest ratios.

Comparability of bioaccumulation within the sanddab guild in coastal Southern California

Most assessments of fish contamination in Southern California use ecologically different species from different sites. Use of ecologically similar species (a guild) might provide better assessments of fish contamination across different sites and depths. In July-August 1997, we collected samples of four sanddab guild species at 22 sites where species pairs co-occurred and determined total DDT concentrations in homogenized whole fish composites. Log-transformed DDT concentrations were highly correlated among all species pairs within this guild. All relationships were linear over the range observed, with slopes not statistically different from unity. The variability in response among species was about four times the variability encountered among replicates within species, but 15 times smaller than the variability among sites. Together, these results suggest that the sanddab guild, widespread on soft bottoms of the Southern California coastal shelf, can be used as a "superspecies" in bathymetrically diverse regional assessments of fish tissue contamination.

Activation of metabotropic glutamate receptors by repetitive stimulation in auditory cortex

To determine whether metabotropic glutamate receptors (mGluRs) contribute to the responses of neurons to repetitive stimulation in the rat auditory cortex in vitro, five stimulus pulses were delivered at 2-100 Hz which elicited five depolarizing synaptic responses, f-EPSPs: f-EPSPs(1-5). Stimulus pulses 2-5 delivered at low frequencies (2-10 Hz) elicited f-EPSPs(2-5) that were about 15% smaller than the response elicited by the first pulse (f-EPSP(1)). In the presence of the nonspecific mGluR agonist, ACPD, the amplitude of all f-EPSPs was 40% smaller than predrug responses. APV, CNQX, or bicuculline (antagonists of NMDA-, AMPA/kainate-, and GABA(A)-receptors, respectively) did not change this effect of ACPD. The mGluR antagonist, MCPG, had no effect on f-EPSPs but did reduce the effect of ACPD. High-frequency stimulation (50-100 Hz) elicited f-EPSPs that were smaller with each successive stimulus. In ACPD, f-EPSP(1) was 40% smaller than predrug, but f-EPSPs(3-5) were not changed compared to pre-ACPD f-EPSPs(3-5), indicating that ACPD occludes the effect of repetitive stimulation. MCPG increased f-EPSP(5) by 15%, indicating that a portion of the reduction of f-EPSPs during high-frequency stimulation is mediated by mGluRs. MCPG also partially blocked the effect of ACPD. In CNQX, ACPD only decreased EPSPs, but APV or bicuculline did not change the effect of ACPD. These results suggest that the successive reduction of f-EPSPs during a high-frequency train is partially a result of mGluR activation.

A comparison of plastic and plankton in the north Pacific central gyre

The potential for ingestion of plastic particles by open ocean filter feeders was assessed by measuring the relative abundance and mass of neustonic plastic and zooplankton in surface waters under the central atmospheric high-pressure cells of the North Pacific Ocean. Neuston samples were collected at 11 random sites, using a manta trawl lined with 333 u mesh. The abundance and mass of neustonic plastic was the largest recorded anywhere in the Pacific Ocean at 334271 pieces km2 and 5114 g km2, respectively. Plankton abundance was approximately five times higher than that of plastic, but the mass of plastic was approximately six times that of plankton. The most frequently sampled types of identifiable plastic were thin films, polypropylene/monofilament line and unidentified plastic, most of which were miscellaneous fragments. Cumulatively, these three types accounted for 99% of the total number of plastic pieces.

Cholinergic synaptic potentials in the supragranular layers of auditory cortex

Receptive-field plasticity within the auditory neocortex is associated with learning, memory, and acetylcholine (ACh). However, the interplay of elements involved in changing receptive-fields remains unclear. Herein, we describe a depolarizing and a hyperpolarizing potential elicited by repetitive stimulation (20-100 Hz, 0.5-2 sec) and dependent on ACh, which may be involved in modifying receptive-fields. These potentials were recorded, using whole cell techniques, in layer II/III pyramidal cells in the rat auditory cortex in vitro. Stimulation at low stimulus intensities can give rise to a hyperpolarizing response and stimulation at higher stimulus intensities can elicit a depolarizing response. The depolarizing response had a reversal potential of -35 mV, and was reduced by the combination of AMPA/kainate and NMDA glutamate receptor antagonists (AMPA/kainate: CNQX, DNQX, and GYKI 52466; NMDA: APV, MK-801) and by the muscarinic ACh receptor antagonist atropine. The hyperpolarizing response had a reversal potential of -73 mV and could be reduced by atropine, GABA(A) receptor antagonists (bicuculline and a Cl(-) channel blocker picrotoxin), and to a small extent a GABA(B) receptor antagonist (saclofen). This suggests that the hyperpolarizing response is likely to be mediated by ACh acting on GABAergic interneurons. Extracellular recordings, also made from layer II/III of cortical slices, yielded a negative-going potential which was reduced by ionotropic glutamate receptor antagonists (same as above) and by the ACh receptor antagonists atropine and scopolamine, suggesting that this potential was the extracellular representation of the depolarizing response.

Intraosseous hemangioma of the zygoma: CT and MR findings

Intraosseous hemangiomas are uncommon, constituting less than 1% of all osseous tumors. The most frequent sites are the calvaria and the vertebral column. Involvement of the facial bones is rare, and occurs most commonly in the maxilla, mandible, and nasal bones. Only 20 cases of zygomatic involvement have been reported in the English-language literature. We report a case of an intraosseous hemangioma of the zygoma documented by CT and MR studies.

Composition and distribution of beach debris in Orange County, California

Many studies have quantified debris collected on beaches around the world. Only a few of those studies have been conducted in the United States, and they are largely limited to semi-quantitative efforts performed as part of volunteer clean-up activities. This study quantifies the distribution and composition of beach debris by sampling 43 stratified random sites on the Orange County, California coast, from August to September 1998. We estimated that approximately 106 million items, weighing 12 metric tons, occur on Orange County beaches. The most abundant items were pre-production plastic pellets, foamed plastics, and hard plastics. Debris density on the remote rocky shoreline was greater than that on high-use sandy beaches for most debris items. This finding partially reflects the periodic clean-up of high-use beaches by local municipalities, and also indicates that a high percentage of the observed debris was transported to the site from waterborne sources.

Imaging of musculoskeletal and spinal tuberculosis

The diagnosis of tuberculosis of the musculoskeletal system is difficult for many reasons. As Walker states, to diagnose tuberculosis one must consider the possibility. The uncommonness of osteoarticular MTb results in clinician inexperience, which leads to overlooking the diagnosis. Subtle early manifestations may elude detection. Negative skin tests and normal chest films do not exclude the consideration of tuberculosis. The most conclusive means of reaching the diagnosis (biopsy and culture) necessitate invasive procedures that are not always definitive, and may require repeated attempts. Management and surgical decisions, however, rely on prompt diagnosis; diagnostic delay has prognostic implications and results in significant morbidity. Musculoskeletal tuberculosis produces no pathognomonic imaging signs, and in advanced stages mimics other disease processes. Despite these difficulties, the diagnostician's goal is to catch the disease as early as possible, because antibiotic treatment can lead to resolution and obviate more radical management. The radiologist must be aware of the groups at greatest risk, and typical and atypical presentations at imaging. The eventual eradication of MTb is conceivable, although not presently within our grasp. Maintaining reasonable suspicion and developing cognizance of the patterns of presentation allow the radiologist to diagnose efficiently the patient who presents with osteoarticular tuberculosis.

Metabotropic glutamate receptors modify ionotropic glutamate responses in neocortical pyramidal cells and interneurons

In neocortex glutamate activates ionotropic and metabotropic receptors (mGluRs). Whole-cell current-clamp recordings in the in vitro rat auditory cortex at 32 degrees C were used to explore the role that mGluRs have in regulation of AMPA/kainate, NMDA, and GABA receptor-mediated synaptic transmission. Our findings are: (a) The fast EPSP (AMPA/kainate), slow EPSP (NMDA), and IPSPs (GABAA, GABAB), elicited in pyramidal neurons are reduced in the presence of (1S,3R)-ACPD (mGluR agonist) with greatest effect on the slow IPSP>fast IPSP>>fast EPSP. The effect is likely the result of ACPD acting at presynaptic mGluRs because the probability of release of glutamate and GABA is reduced in the presence of ACPD, intracellular infusion of a G protein antagonist (GDPPS) did not block the effect of ACPD, nor were iontophoretic kainic acid or NMDA-induced depolarizations reduced by ACPD. (b) The slow EPSP is enhanced following washout of ACPD and enhancement is not due to disinhibition because it is present in the absence of IPSPs, but if IPSPs are present, its magnitude can be influenced. Iontophoretic NMDA responses are enhanced in the presence of ACPD, an effect blocked by GDPbetaS and heparin (intracellular inositol 1,4,5-trisphosphate receptor antagonist). Taken together, this evidence suggests that enhancement is a result of group I postsynaptic mGluR activation. (c) In fast-spiking cells ACPD reduces the EPSP (AMPA/kainate and NMDA-mediated). This action is likely presynaptic because it persists when GDPbetaS is in the cells. (d) The rate of spike discharge recorded from fast-spiking cells is accelerated in ACPD but does not change in the presence of GDPbetaS, suggesting a postsynaptic effect. Our data indicate that mGluRs can influence neocortical synaptic transmission in complex ways by acting presynaptically and postsynaptically.

Central versus peripheral mediation of naloxone's perfusion effects in endotoxic rats

Opioid receptor antagonists can act centrally and peripherally. It is unclear if these 2 pathways differentially mediate the perfusion-associated effects of opioid antagonism during endotoxemia. Male, Sprague-Dawley rats (340-390 g) were surgically prepared with left ventricular, tail artery, and jugular vein catheters 24 h before experiments were begun. Conscious, unrestrained rats were challenged with Escherichia coli lipopolysaccharide (LPS; 2 mg/kg/hr over 30 min) infusion. Measurements of regional blood flows were made using radioactive microspheres prior to (baseline), and at 60 and 120 min after LPS infusion. Saline (1 mL/kg bolus + 0.5 mL/kg/h infusion), naloxone (Nlx; 4 mg/kg bolus + 2 mg/kg/h infusion), or naloxone methyl bromide (Nlx-mb; 4.64 mg/kg, bolus + 2.32 mg/kg/h infusion) were administered 40 min after LPS infusion was begun. Nlx-mb does not cross the blood-brain barrier, and was thus used to differentiate central from peripherally mediated responses. At the end of each experiment, blood samples were collected for determination of ET-1 and nitric oxide metabolites (NOx = NO3 + NO2) using enzyme-linked immunosorbent assay (ELISA) and Griess reaction methods, respectively. Endotoxemia produced a significant decrease in cardiac output and an increase in systemic vascular resistance. Treatment with Nlx or Nlx-mb significantly attenuated the endotoxin-induced elevation in systemic vascular resistance and the decrease in cardiac output at 60 min after induction of endotoxemia compared with their respective baseline values. Nlx and Nlx-mb also attenuated the endotoxin-induced increases in hepatic portal and skeletal vascular resistances. These observations suggested that the ameliorative effect of Nlx on endotoxemia-induced regional vascular resistance alterations was mediated via peripheral opioid receptor mechanisms. However, although Nlx attenuated the endotoxin-induced decreases in the blood flow to the stomach and pancreas, Nlx-mb attenuated the endotoxin-induced decreases in the blood flow to the small intestine and cecum, in addition to the pancreas and, to some extent, the stomach. As such, separate central and peripherally mediated actions of opioid receptor antagonism were indicated. Nlx also resulted in an increase in the plasma levels of ET-1 only, whereas Nlx-mb increased the plasma levels of ET-1 and NOx. These observations suggest that separate central and peripheral effects of opioids during endotoxemia play a role in the associated circulatory alterations, and may differentially affect the release and/or synthesis of vasoactive mediators that might be related to their varied hepatosplanchnic vascular response during endotoxemia.

Aging and meaning in life: examining the concept

To make sense of their existence in the face of adversity and chaos or during times of relative calm, human beings seek meaning. Meaning has been identified as a significant factor in health and well-being in later years. Engaging in an intensive literature search about meaning in later life constituted the beginning step for a qualitative research study. By studying how older people experience meaning in their lives, we may learn more about the human experiences of joy and hope and their capacity to respond to opportunities and manage problems in their lives.

MR imaging of the biceps muscle-tendon complex

The anatomy of the biceps brachii muscle-tendon complex is reviewed. Particular attention is given to the tendon of the long head. Pathologic conditions affecting the biceps are discussed with respect to clinical features and current ideas regarding pathogenesis, which are correlated with the appearance at MR imaging.