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Objectives: The LYMQOL is the most frequently translated, validated, objective tool for assessing Health-Related Quality of Life (HRQoL) in individuals with upper limb lymphedema (ULL). There have been adaptations and validations in a number of different countries. While a German version of LYMQOL Leg for lower limb lymphedema is available, a validated translation of LYMQOL Arm to German is lacking. We aimed to perform a cross-cultural adaption and translation according to ISPOR principles. Methods: Patients suffering from ULL from Germany, Austria, and Switzerland (n = 52) were questioned twice using the translated LYMQOL Arm, SF-36, and an evaluation questionnaire. The assessment of the content validity and face validity proved this version of LYMQOL Arm to be acceptable for interviewing German-speaking patients with ULL in Germany. Results: Comparison of LYMQOL Arm and SF-36 demonstrated good construct validity. Test–retest reliability was moderate to good (intraclass correlation coefficients 0.66–0.73). Cronbach’s alpha values varied between 0.79 and 0.89 in both interviews, indicating good internal consistency. Factor analysis revealed a cumulative variance of 59.5% for the four domains of the questionnaire. Conclusion: There was no significant association between lymphedema stage and LYMQOL Arm score. This trial tested the appropriateness of the German version of the LYMQOL Arm for measuring HRQoL in German-speaking individuals with ULL.

Objectives To understand the lived experience of adults with overweight/obesity and early type 2 diabetes in a modern urban environment, and the interrelations among the various aspects of these experiences and participants’ attitudes to weight management.Design Qualitative inductive approach to analysing data thematically from semistructured interviews and interpreted from a socioecological perspective.Setting Primary care clinics located in northern and central Singapore.Participants 21 patients between 29 and 59 years old who are living with overweight/obese (Body Mass Index of 25.3–44.0kg/m2) and type 2 diabetes for 6 years or less.Results The main themes – everyday life, people around me and within me – pointed to a combination of barriers to weight and health management for participants. These included environmental factors such as easy physical and digital access to unhealthy food, and high-stress work environments; social factors such as ambiguous family support and dietary practices of peers; and individual factors such as challenges with self-regulation, prioritising work, dealing with co-existing medical conditions and the emotional significance of food. While lack of motivation and cultural dietary practices are hard to change, a problem-solving attitude, and presence of role models, may enable behaviour change.Conclusion An exploration of the lifeworld of patients with overweight/obese and early type 2 diabetes revealed that work demands, dietary practices in the workplace and at home, and the easy availability of calorie-dense foods afforded by a technology-infused environment hindered the individual’s efforts at maintaining a healthy weight and lifestyle. Policy and initiatives promoting work-life balance as well as individualised interventions can support participants’ stress management, and problem-solving capability for behaviour change. These barriers stemmed from the various domains of the environmental, interpersonal and intrapersonal but were interrelated. They underscored the need for an integrated approach to weight and diabetes management.

The LYMQOL Leg questionnaire is the most widely used, evidence-based tool for the assessment of health-related quality of life (HRQoL) in patients with lower limb lymphedema (LLL). It has been translated into several languages, but a German version is currently lacking. The aim of our study was to validate a German translation of LYMQOL Leg. Translation and cross-cultural adaptation were performed in accordance with ISPOR principles. A total of 103 patients with LLL from Germany, Austria, and Switzerland were interviewed twice. The content and face validity assessments indicated that the German LYMQOL Leg questionnaire was acceptable for interviewing patients with lymphedema. Comparing the LYMQOL Leg with the SF-36 demonstrated good construct validity. Reliability determined by the test–retest procedure was good (intra-class-correlation coefficients 0.68–0.92). Cronbach’s alpha values ranged from 0.76 to 0.90 in both interviews, showing an acceptable internal consistency. The four domains of the questionnaire reached a cumulative variance of 52.7% in the factor analysis. The association between the lymphedema stages and the LYMQOL Leg domain scores was not significant. In conclusion, the validity of the German version of LYMQOL Leg, called LYMQOL Bein, was confirmed and thus represents a suitable tool for measuring HRQoL in German-speaking patients with LLL.

Immunosuppressed kidney transplant (KT) recipients produce a weaker response to COVID-19 vaccination than immunocompetent individuals. We tested antiviral IgG response in 99 KT recipients and 66 healthy volunteers who were vaccinated with mRNA-1273 Moderna or BNT162b2 Pfizer-BioNTech vaccines. A subgroup of participants had their peripheral blood leukocytes (PBLs) evaluated for the frequency of T helper 1 (Th1) cells producing IL-2, IFN-γ and/or TNF-α, and IL-10-producing T-regulatory 1 (Tr) cells. Among KT recipients, 45.8% had anti-SARS-CoV-2 IgG compared to 74.1% of healthy volunteers (p = 0.009); also, anti-viral IgG levels were lower in recipients than in volunteers (p = 0.001). In terms of non-responders (≤2000 U/mL IgG), Moderna’s group had 10.8% and Pfizer-BioNTech’s group had 34.3% of non-responders at 6 months (p = 0.023); similarly, 15.7% and 31.3% were non-responders in Moderna and Pfizer-BioNTech groups at 12 months, respectively (p = 0.067). There were no non-responders among controls. Healthy volunteers had higher Th1 levels than KT recipients, while Moderna produced a higher Th1 response than Pfizer-BioNTech. In contrast, the Pfizer-BioNTech vaccine induced a higher Tr1 response than the Moderna vaccine (p < 0.05); overall, IgG levels correlated with Th1(fTTNF-α)/Tr1(fTIL-10) ratios. We propose that the higher number of non-responders in the Pfizer-BioNTech group than the Moderna group was caused by a more potent activity of regulatory Tr1 cells in KT recipients vaccinated with the Pfizer-BioNTech vaccine.

Venous thromboembolism has been associated with high morbidity and mortality, with a cost burden for the U.S. health care system owing to secondary complications such as pulmonary embolism and post-thrombotic syndrome. The current standard of therapy for acute deep vein thrombosis (DVT) is anticoagulation. For patients with venous outflow obstruction of the iliac vein system, several minimally invasive recanalization techniques are now available. In the present report, we have described a case of bilateral internal iliac DVT that had progressed to right-sided iliofemoral DVT in a young athletic adult, in the absence of anatomic abnormalities, that was treated with thrombolysis-free mechanical thrombectomy.

Adult chimpanzees Tatu and Loulis lived at the Fauna Foundation sanctuary. They had acquired signs of American Sign Language (ASL) while young and continued to use them as adults. Caregivers with proficiency in ASL maintained daily sign language records during interactions and passive observation. Sign checklists were records of daily vocabulary use. Sign logs were records of signed interactions with caregivers and other chimpanzees. This study reports sign use from eight years of these records. Tatu and Loulis used a majority of their base vocabularies consistently over the study period. They used signs that they had acquired decades earlier and new signs. Their utterances served a variety of communicative functions, including responses, conversational devices, requests, and descriptions. They signed to caregivers, other chimpanzees, including those who did not use signs, and to themselves privately. This indicates the importance of a stimulating and interactive environment to understand the scope of ape communication and, in particular, their use of sign language.

Genomic medicine, an emerging medical discipline, applies the principles of evolution, developmental biology, functional genomics, and structural genomics within clinical care. Enabling widespread adoption and integration of genomic medicine into clinical practice is key to achieving precision medicine. We delineate a biological framework defining diagnostic utility of genomic testing and map the process of genomic medicine to inform integration into clinical practice. This process leverages collaboration and collective cognition of patients, principal care providers, clinical genomic specialists, laboratory geneticists, and payers. We detail considerations for referral, triage, patient intake, phenotyping, testing eligibility, variant analysis and interpretation, counseling, and management within the utilitarian limitations of health care systems. To reduce barriers for clinician engagement in genomic medicine, we provide several decision-making frameworks and tools and describe the implementation of the proposed workflow in a prototyped electronic platform that facilitates genomic care. Finally, we discuss a vision for the future of genomic medicine and comment on areas for continued efforts.

The goals of zoos are providing an entertaining and educational experience for visitors, promoting environmental conservation, and promoting positive welfare for nonhuman residents. Education can unify these goals. In this study, data were collected on visitors to the chimpanzee (Pan troglodytes) exhibit at The Zoo Northwest Florida. Researchers implemented three conditions of education at the chimpanzee viewing platform: a graphic sign, a trained docent, and a control condition with no intervention. The sign and docent encouraged visitors to use affinitive chimpanzee behaviors. Visitors were significantly more active in the graphic sign condition and significantly less active in the docent condition, and their behavior did not vary from the expected value during the control condition. Visitors used the affinitive behaviors that were demonstrated in each experimental condition. These results suggest that both graphic signs and docent interaction affect visitor behavior and can be considered useful educational tools for fulfilling the goals of the zoos.

Technology-based supports offer promise for helping elementary school teachers implement Tier 2 interventions to address challenging student behavior. The Daily Report Card Online (DRCO) platform is a cloud-based web application designed to support teachers’ adoption and implementation of a high-quality daily report card (DRC) intervention through the use of professional development resources, guided intervention design workflows, algorithm-based decision-making tools, and real-time progress monitoring. We examined teacher adoption, adaptation, and implementation of a DRC intervention when using the DRCO platform with support from a consultant during the 2021–2022 school year. Participants were 29 teachers, 20 of whom used the DRCO to implement a DRC with a student (n = 20). The most frequently chosen target behaviors were student interruptions, non-compliance, and work completion. When using the DRCO platform, teachers achieved several procedures that align with evidence-based guidelines (e.g., screening, baseline tracking, setting achievable goals, tracking behaviors over time). However, goal criterion changes and shaping procedures were used less often than expected. Despite the option to track behaviors solely with technology, 60% of teachers tracked student behaviors via paper methods (e.g., printed the DRC card, used sticky notes). Adaptations were made by 40% teachers; however, all adaptations involved modifying printed materials to be more student-friendly (e.g., add clipart to the DRC) and did not change the guiding principles of the intervention. Tau-effect sizes for academic and behavioral target behaviors on the DRC showed small to moderate change over time and change in target behaviors showed some association with change in global teacher ratings. Lastly, we identified associations between teacher characteristics and adoption and implementation, as well as associations between implementation and student outcomes.

Abstract The Enhanced Recovery After Surgery (ERAS) protocol affected traditional cardiac surgery processes and COVID-19 is expected to accelerate its scalability. The aim of this study was to assess the impact of an ERAS-based protocol on the length of hospital stay after cardiac surgery. From January 2019 to June 2020, 664 patients underwent consecutive cardiac surgery at a Latin American center. Here, 46 patients were prepared for a rapid recovery through a multidisciplinary institutional protocol based on the ERAS concept, the “TotalCor protocol”. After the propensity score matching, 46 patients from the entire population were adjusted for 12 variables. Patients operated on the TotalCor protocol had reduced intensive care unit time (P 70% adherences. In conclusion, the TotalCor protocol was safe and effective for a 3-day discharge after cardiac surgery. Postoperative atrial fibrillation and renal failure were predictors of postoperative stay > 5 days.

Compassion fatigue is defined as “traumatization of helpers through their efforts at helping others”. It has negative effects on clinicians including reduced satisfaction with work, fatigue, irritability, dread of going to work, and lack of joy in life. It is correlated with patients’ decreased satisfaction with care. Compassion fatigue occurs in a variety of helping professions including educators, social workers, mental health clinicians, and it also appears in nonhuman animal care workers. This study surveyed caregivers of chimpanzees using the ProQOL-V to assess the prevalence of compassion fatigue among this group. Compassion satisfaction is higher than many other types of animal care workers. Conversely, this group shows moderate levels of burnout and secondary traumatic stress; higher levels than other types of animal care workers and many medical professions. While compassion fatigue has an effect on the caregiver’s experience, it has potential to affect animal welfare. Caregivers are an integral part of the chimpanzee social network. Compassion fatigue affects the caregiver’s attitude, this could in turn affect the relationship and degrade the experience of care for captive chimpanzees. Compassion fatigue can be mitigated with professional development, mindfulness training, interrelationships among staff, and specialized training. This preliminary assessment indicates the work ahead is educating caregivers about compassion fatigue and implementing procedures in sanctuaries to mitigate burnout and secondary traumatic stress.

Establishing a positive peer climate in elementary school classrooms is an important goal for educators because peer dynamics are thought to affect academic learning. Thus, it is important to (a) understand the relationship between children's peer dynamics and academic functioning, and (b) identify teacher practices that influence both peer processes and academic outcomes. In this pilot study, we explored whether specific teacher strategies that promote positive behaviors in children and positive peer dynamics influence children's better academic enablers, as well as whether they do so indirectly via improving peer sociometric ratings. Such teacher strategies may be particularly relevant for supporting children who demonstrate impairment in both social and academic domains, such as children at risk for attention-deficit/hyperactivity disorder (ADHD). Thus, we also examined whether these relationships differ for children with elevated ADHD symptoms and peer problems (i.e., target students), relative to classmates (i.e., non-target students). Participants were 194 children in the classrooms of 12 teachers (grades K-4) who participated in an open-trial pilot study of the school-based version of the Making Socially Accepting Inclusive Classrooms (MOSAIC) program. In the fall and spring of a school year, we assessed children's sociometric ratings received from peers, and academic enabler skills as rated by teachers. Throughout one academic year, we obtained assessments of teachers' use of MOSAIC strategies (observed and self-reported). Results showed that, after accounting for fall academic enablers, the teacher strategy of CARE time (involving one-on-one interaction with the student to build the teacher-student relationship) was positively associated with spring academic enablers. However, findings did not support the hypothesized indirect effect of peer sociometric ratings on the relationship between teacher strategy use and academic enablers, or the moderated indirect effect by target student status. Implications for future research and classroom interventions are discussed.

Abstract Problem Smartphone applications are an increasingly useful part of patients' self‐management of chronic health conditions. Asthma is a common chronic health condition for which good self‐management by patients is very helpful in maintaining stability. User‐centered design and intelligent systems that learn are steps forward in building applications that are more effective in providing quality care that is scalable and tailored to each patient. Methods A literature and application store search to review historic and current asthma smart phone applications. User‐centered design is a methodology that involves all stakeholders of a proposed system from the beginning of the design phase to the end of installation. One aspect of this user‐centered approach involved conducting focus groups with patients and health care providers to determine what features they desire for use in applications and create a model to build smart infrastructure for a learning health care system. A simple prototype for an asthma smartphone application is designed and built with basic functionality. Outcomes Only one publication in the literature review of asthma smartphone applications describes both user‐centered design and intelligent learning systems. The authors have presented a set of user‐desired attributes for a smart health care application and a possible data flow diagram of information for a learning system. A prototype simple user‐centered designed asthma smartphone application that better assists patients in their care illustrates the value of the proposed architecture. Discussion Our user‐centered approach helped design and implement a learning prototype smart phone application to help patients better manage their asthma and provide information to clinical care providers. While popular in other industries, user‐centered design has had slow adoption in the health care area. However, the popularity of this approach is increasing and will hopefully result in mobile application that better meets the needs of both patients and their care providers.

Abstract Background To explore the hypothesis that maternal periodontitis is associated with increased risk for Intrauterine Growth Restriction (IUGR), we examined the risk of IUGR in relation to periodontal treatment before, during and after pregnancy. Methods We conducted a retrospective cohort analysis of insurance claims data from 2009 to 2012 for women who delivered a singleton live birth (n = 32,168). IUGR was examined as a function of type and timing of dental treatment, adjusting for potential confounders in logistic regression. Sensitivity analysis evaluated the potential effects of unmeasured confounding. Results Women who received periodontal treatment after delivery, indicating the presence of untreated periodontal disease during pregnancy, had significantly higher odds of IUGR compared to women who received no periodontal treatment (adjusted OR 1.5, 95% CI 1.2, 1.8). Conclusions Periodontal treatment provided in the immediate postpartum period, a proxy for periodontitis during gestation, was associated with increased risk of IUGR.

Introduction to the special issue ‘Teaching Complexity’

In March 2017, highly pathogenic (HP) and low pathogenic (LP) avian influenza virus (AIV) subtype H7N9 were detected from poultry farms and backyard birds in several states in the southeast United States. Because interspecies transmission is a known mechanism for evolution of AIVs, we sought to characterize infection and transmission of a domestic duck-origin H7N9 LPAIV in chickens and genetically compare the viruses replicating in the chickens to the original H7N9 clinical field samples used as inoculum. The results of the experimental infection demonstrated virus replication and transmission in chickens, with overt clinical signs of disease and shedding through both oral and cloacal routes. Unexpectedly, higher levels of virus shedding were observed in some cloacal swabs. Next generation sequencing (NGS) analysis identified numerous non-synonymous mutations at the consensus level in the polymerase genes (i.e., PA, PB1, and PB2) and the hemagglutinin (HA) receptor binding site in viruses recovered from chickens, indicating possible virus adaptation in the new host. For comparison, NGS analysis of clinical samples obtained from duck specimen collected during the outbreak indicated three polymorphic sides in the M1 segment and a minor population of viruses carrying the D139N (21.4%) substitution in the NS1 segment. Interestingly, at consensus level, A/duck/Alabama (H7N9) had isoleucine at position 105 in NP protein, similar to HPAIV (H7N9) but not to LPAIV (H7N9) isolated from the same 2017 influenza outbreak in the US. Taken together, this work demonstrates that the H7N9 viruses could readily jump between avian species, which may have contributed to the evolution of the virus and its spread in the region.

Abstract Cell‐intrinsic metabolic reprogramming is a hallmark of cancer that provides anabolic support to cell proliferation. How reprogramming influences tumor heterogeneity or drug sensitivities is not well understood. Here, we report a self‐organizing spatial pattern of glycolysis in xenograft colon tumors where pyruvate dehydrogenase kinase (PDK1), a negative regulator of oxidative phosphorylation, is highly active in clusters of cells arranged in a spotted array. To understand this pattern, we developed a reaction–diffusion model that incorporates Wnt signaling, a pathway known to upregulate PDK1 and Warburg metabolism. Partial interference with Wnt alters the size and intensity of the spotted pattern in tumors and in the model. The model predicts that Wnt inhibition should trigger an increase in proteins that enhance the range of Wnt ligand diffusion. Not only was this prediction validated in xenograft tumors but similar patterns also emerge in radiochemotherapy‐treated colorectal cancer. The model also predicts that inhibitors that target glycolysis or Wnt signaling in combination should synergize and be more effective than each treatment individually. We validated this prediction in 3D colon tumor spheroids.

Atopic dermatitis (AD) and narcolepsy type 1 (NT1) are two distinct diseases that have not been classically shown to be related. The potential connection between the known immunological aetiology of AD and the proposed autoimmune pathophysiology of dysregulation in NT1; however, is the subject of ongoing speculation and debate with advances in gene sequencing and technology. Here, we present a case of a patient with concomitant refractory AD and NT1 and review the current research on their immunological relationship and the challenges in management relative to disease burden and psychiatric comorbidities.

Understanding general education teachers' experiences with and goals for school-based consultation is warranted to address class-wide and individual student concerns. In a sample of 66 general education teachers, we described their experiences with: (1) informal consultation with colleagues; (2) school team meeting consultation; and (3) ongoing, structured consultation. Results indicated teachers received consultation most often for challenging individual student behavior and individual student academics (rather than for class-wide behavior management or academic instruction) and received consultation from teachers and administrators (rather than from school psychologists or behavioral consultants). Teachers reported higher satisfaction during informal consultations than in team meetings. When teachers received ongoing, structured consultation, most reported three or more sessions with one to two observations. Implications for assessing and improving school-based teacher consultation are discussed.

Research regarding noninvasive brain stimulation technologies for the treatment of mild traumatic brain injury (mTBI), posttraumatic stress disorder (PTSD), and mixed (mTBI/PTSD) trauma syndromes has been increasing exponentially. Technologies with the greatest potential thus far include repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and cranial electrotherapy stimulation (CES). The nature and some of the controversies distinguishing mTBI, PTSD, and mTBI/PTSD are reviewed along with evidence for shared underlying mechanisms. An overview of treatment applications for rTMS, tDCS, and CES are also reviewed. A novel variant of a minute pulsed electromagnetic stimulation technology linked to ongoing electroencephalograph monitoring known as the Flexyx Neurotherapy System is introduced with an overview of the technology and technique, as well as a summary of supportive data to date that explores potential applications for amelioration of these syndromes.

Background and objectives: Medical school curricula increasingly seek to promote medical students’ commitment to redressing health disparities, but traditional pedagogical approaches have fallen short of this goal. The objective of this work was to assess the value of using community-based guided tours of disadvantaged neighborhoods to fill this gap. Methods: A total of 50 second-year medical students participated in a guided tour of disadvantaged public housing neighborhoods in Richmond, Virginia. Students completed self-reflexive writing exercises during a post-tour debriefing session. Student writings were analyzed to assess the tour’s effect on their awareness of poverty’s impact on vulnerable populations’ health and wellbeing, and their personal reactions to the tour. Results: Student writings indicated that the activity fostered transformative learning experiences around the issue of poverty and its effects on health and stimulated a personal commitment to working with underserved populations. Themes from qualitative analysis included: increased awareness of the extent of poverty, enhanced self-reflexive attitude towards personal feelings, biases and misperceptions concerning the poor, increased intentional awareness of the effects of poverty on patient health and well-being, and, encouragement to pursue careers of medical service. Conclusions: This pilot demonstrated that incorporating self-reflexive learning exercises into a brief community-based guided tour can enhance the social consciousness of medical students by deepening understandings of health disparities and promoting transformative learning experiences.

Patients with human immunodeficiency virus (HIV) have an increased risk of inoculation with nontyphoid Salmonella compared to the general population. While nontyphoid Salmonella commonly manifests as gastroenteritis, Salmonella bacteremia can be seen in patients with HIV. We present a case of disseminated Salmonellosis in a patient with HIV complicated by bronchopleural fistula and secondary empyema. Case Presentation. A 40-year-old African American male with HIV noncompliant with HAART therapy presented with complaints of generalized weakness, weight loss, cough, night sweats, and nonbloody, watery diarrhea of four weeks’ duration. A computed tomography (CT) scan demonstrated a bilobed large, thick-walled cavitary lesion in the right upper lobe communicating with the pleural space to form a bronchopleural fistula. Thoracentesis yielded growth of nontyphi Salmonella species consistent with empyema; he was treated with intravenous Ceftriaxone and underwent placement of chest tube for drainage of empyema with instillation of alteplase/dornase twice daily for three days. Repeat CT chest showed a hydropneumothorax. The patient subsequently underwent video-assisted thoracoscopy with decortication. The patient continued to improve and follow-up CT chest demonstrated improved loculated right pneumothorax with resolution of the right bronchopleural fistula and resolution of the cavitary lesions. Discussion. We describe one of the few cases of development of bronchopulmonary fistula and the formation of empyema in the setting of disseminated Salmonella. Empyema complicated by bronchopulmonary fistula likely led to failure of intrapleural fibrinolytic therapy and the patient ultimately required decortication in addition to antibiotics. While Salmonella bacteremia can be seen in immunocompromised patients, extraintestinal manifestations of Salmonella infection such as empyema and bronchopleural fistulas are uncommon. Bronchopleural fistulas most commonly occur as a postoperative complication of pulmonary resection. Conclusions. This case highlights the unusual pulmonary manifestations that can occur due to disseminated Salmonella in an immunocompromised patient as well as complex management decisions related to these complications.