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With benefits to patient outcomes, provider burden, and health system costs, the goal of reducing hospital readmissions for patients with diabetes mellitus (DM) is multifaceted. Current studies have neither elucidated a clear approach to accurately identify at-risk patients nor implemented reliable interventions to significantly reduce readmissions. We trialed a Quality Improvement project utilizing a diabetes Nurse Practitioner (NP)/Certified Diabetes Care and Education Specialist (CDCES) to see at-risk patients during initial hospitalization and in close clinic follow-up after discharge with an endpoint of reducing future readmissions. Over 21 months, 79 hospitalized patients with DM were identified as high-risk for readmission. Identifying factors included previous admission, DKA/HHS, new DM diagnosis, new to insulin, high-dose steroid use, or provider discretion. The NP/CDCES provided DM management, education, and coordinated discharge. Patients were called shortly after discharge and had a 2-4 week clinic follow-up with the NP/CDCES. The primary endpoint was number of readmissions 180 days post-discharge after NP/CDCES intervention versus number of previous readmissions pre-intervention. Change in hemoglobin A1C, time to post-hospital phone call, and time to outpatient follow-up were also evaluated. Pre- and post-intervention readmission rates remained unchanged; average pre-intervention readmissions per patient was 1.7 versus 1.88 post-intervention readmissions (p=0.74). However, a secondary endpoint of reduction in A1C was statistically significant, with a mean decrease in A1C of 0.97% per patient (p=0.0025). Time to post-hospital phone call and early follow-up did not affect readmission rates. While targeted inpatient-to-outpatient intervention for high-risk patients with DM did not reduce readmission rates, our data suggests coordinated inpatient intervention with close hospital follow-up may improve A1C in high-risk patients with diabetes. Disclosure A. Harris: None. K. Grdinovac: None.

Abstract. Anabolic Androgenic Steroids (AAS) usage has been repeatedly linked with a body image disorder called Muscle Dysmorphia (MD). However, evidence for how this relationship manifests is currently inconclusive. This study focused on the extent to which MD may precipitate or perpetuate the use of AAS. Utilizing a cross-sectional design, the sample consisted of 57 users (current and lifetime) and 51 non-using (never used AAS) bodybuilders recruited from two bodybuilding dedicated gymnasiums located in Wales, UK. Significantly higher levels of MD were found in users compared to non-users across training experience duration (0–2, 3–5, and 6+ years). MD levels irrespective of AAS usage (users vs. non-users) were consistent between 0–2 and 3–5 years of training declining however between those of 6+ years training experience. No differences were reported in symptoms of MD between users of AAS with varying lengths of AAS use exposure. This provides preliminary evidence suggesting MD may influence both initiation and maintenance of AAS use; however, neither regular gym attendance nor prolonged AAS usage may exacerbate MD symptoms.

Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.

There is a plethora of published research reporting the wealth and breadth of biopsychosocial benefits of physical activity; however, a recent Cochrane systematic review concluded insufficient evidence for current population level physical activity interventions, citing scalability as a major contributory factor, with many of the interventions failing to reach a substantial proportion of the community. The current study aimed to conduct a pilot evaluation of a technology-enabled, gamification-based intervention called Beat the Street and sought to examine the impact of the Beat the Street intervention on self-reported physical activity.In total, n = 329 people completed the International Physical Activity Questionnaire Short Form (I-PAQ-SF) in full at baseline (before the intervention) and follow-up (immediately following the 7-week intervention).Overall, participants increased their weekly walking by +180 minutes per week (P 0.001) and their weekly physical activity by +335 minutes per week (P 0001). Vigorous activity increased by +48 minutes per week (P = 0.004) and moderate activity increased by +60 minutes per week (P 0.001).The findings provide preliminary evidence that the Beat the Street intervention may be a promising approach to increasing physical activity at a community-wide level and warrants further investigation.

// Laurie K. Svoboda 1 , Natashay Bailey 1 , Raelene A. Van Noord 2 , Melanie A. Krook 1 , Ashley Harris 1 , Cassondra Cramer 1 , Brooke Jasman 1 , Rajiv M. Patel 3, 4 , Dafydd Thomas 3 , Dmitry Borkin 3 , Tomasz Cierpicki 3 , Jolanta Grembecka 3 , Elizabeth R. Lawlor 1, 3 1 Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109, USA 2 Department of Surgery, University of Michigan Medical School, Ann Arbor, MI 48109, USA 3 Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109, USA 4 Department of Dermatology, University of Michigan Medical School, Ann Arbor, MI 48109, USA Correspondence to: Elizabeth R. Lawlor, email: elawlor@med.umich.edu Keywords: Ewing sarcoma, trithorax, MLL, menin, HOX Received: August 15, 2016 Accepted: November 14, 2016 Published: November 18, 2016 ABSTRACT Developmental transcription programs are epigenetically regulated by the competing actions of polycomb and trithorax (TrxG) protein complexes, which repress and activate genes, respectively. Ewing sarcoma is a developmental tumor that is associated with widespread de-regulation of developmental transcription programs, including HOX programs. Posterior HOXD genes are abnormally over-expressed by Ewing sarcoma and HOXD13 , in particular, contributes to the tumorigenic phenotype. In MLL1 fusion-driven leukemia, aberrant activation of HOXA genes is epigenetically mediated by the TrxG complex and HOXA gene expression and leukemogenesis are critically dependent on the protein-protein interaction between the TrxG proteins MLL1 and menin. Based on these data, we investigated whether posterior HOXD gene activation and Ewing sarcoma tumorigenicity are similarly mediated by and dependent on MLL1 and/or menin. Our findings demonstrate that Ewing sarcomas express high levels of both MLL1 and menin and that continued expression of both proteins is required for maintenance of tumorigenicity. In addition, exposure of Ewing sarcoma cells to MI-503, an inhibitor of the MLL1-menin protein-protein interaction developed for MLL1-fusion driven leukemia, leads to loss of tumorigenicity and down-regulated expression of the posterior HOXD gene cluster. Together these data demonstrate an essential role for MLL1 and menin in mediating tumor maintenance and posterior HOXD gene activation in Ewing sarcoma. A critical dependency of these tumors on the MLL1-menin interaction presents a potentially novel therapeutic target.

Background The CTOT-11 (Prevention of Cardiac Allograft Vasculopathy Using Rituximab Therapy in Cardiac Transplantation [Clinical Trials in Organ Transplantation-11]) study was a randomized, placebo-controlled, multicenter, double-blinded clinical trial in nonsensitized primary heart transplant (HTX) recipients. Objectives The study sought to determine whether B cell depletion therapy would attenuate the development of cardiac allograft vasculopathy. Methods A total of 163 HTX recipients were randomized to rituximab 1,000 mg intravenous or placebo on days 0 and 12 post-transplant. Primary outcome was change in percent atheroma volume (PAV) from baseline to 1 year measured by intravascular ultrasound. Secondary outcomes included treated episodes of acute rejection, de novo anti-HLA antibodies (including donor-specific antibodies), and phenotypic differentiation of B cells. Results There were no significant differences at study entry between the rituximab and placebo groups. Paired intravascular ultrasound measures were available at baseline and 1 year in 86 subjects (49 rituximab, 37 placebo). The mean ± SD change in PAV at 12 months was +6.8 ± 8.2% rituximab versus +1.9 ± 4.4% placebo (p = 0.0019). Mortality at 12 months was 3.4% rituximab versus 6.8% placebo (p = 0.47); there were no retransplants or post-transplant lymphoproliferative disorder. The rate of treated rejection was 24.7% rituximab versus 32.4% placebo (p = 0.28). Rituximab therapy effectively eliminated CD20+/CD19+ B cells followed by a gradual expansion of a CD19– cell population in the rituximab-treated group. Conclusions A marked, unexpected increase in coronary artery PAV with rituximab was observed during the first year in HTX recipients. One-year mortality was not impacted; however, longer-term follow-up and mechanistic explanations are required. (Prevention of Cardiac Allograft Vasculopathy Using Rituximab [Rituxan] Therapy in Cardiac Transplantation; NCT01278745)

This article analyses Michel Houellebecq’s use of multimedia in order to reveal how he creates transmedial worlds that cross media thresholds. Through plurimedial combinations, expansive adaptations, and post-textual work, Houellebecq extends the realms of creative intervention. Through these three types of activity, Houellebecq troubles textual boundaries and the sacralised and mythologised notions of author and text. His transmedial undertaking addresses artistic marginalisation while encouraging new forms of creative production in a growing space of possibilities. Cet article présente une analyse des œuvres multimédiatiques de Michel Houellebecq afin de démontrer la création de mondes transmédiaux. À travers la création de combinaisons pluri-médiales, d’adaptations expansives et d’œuvres post-textuelles, Houellebecq vise l’extension du domaine des interventions créatives. Il déstabilise les seuils entre les médias et les conceptions sacralisées du texte et de l’écrivain. Houellebecq conteste la marginalisation artistique et encourage de nouvelles formes de production artistiques dans un espace de possibilités croissant.

wilson d.m., harris a., hollis v. & mohankumar d. (2010) Upstream thinking and health promotion planning for older adults at risk of social isolation. International Journal of Older People Nursing6, 282–288 doi: 10.1111/j.1748-3743.2010.00259.x Aims and objectives. To raise awareness of social isolation, and provide an approach to first conceptualise and then prevent social isolation among older community-dwelling persons. Background. Older adults comprise a vulnerable population for social isolation and its associated health risks. Design. Literature review. Methods. Canada’s Population Health Promotion Model was chosen as a comprehensive tool to understand and prevent social isolation. Research studies were sought to identify key health determinants and evidence-based options for preventing social isolation. Results. Around 1 out of 6 older persons are socially isolated and three health determinants are of prime importance: (i) income and social status; (ii) personal health practices and coping skills and (iii) social support networks. Evidence-based interventions targeted to these health determinants are suggested. Conclusion. Nurses are a key group to advocate for actions needed to prevent social isolation. Implications for practice. Nurses can play a vital role in minimising social isolation through a variety of educational, prevention and political lobbying activities.

Mental ill health accounts for 13 per cent of total global disease burden with predictions that depression alone will be the leading cause of disease burden globally by 2030. Poor mental health is consistently associated with deprivation, low income, unemployment, poor education, poorer physical health and increased health-risk behaviour. A plethora of research has examined the relationship between physical activity and mental wellbeing; however, the influence of community-wide gamification-based physical activity interventions on mental wellbeing, to the authors’ knowledge, is yet to be explored. In view of this paucity of attention, the current study examined the relationship between physical activity and mental wellbeing pre/post a community-wide, gamification-based intervention. The findings revealed that increases in mental wellbeing were significantly greater for the least active prior to the intervention, and a strong, positive correlation between increase in physical activity and increase in mental wellbeing was observed.

IDA is a not-for-profit organization that manages DoD-sponsored FFRDCs. Founded in 1947 as the Weapons Systems Evaluation Group, IDA was incorporated in 1956 and has its headquarters in Alexandria, Virginia, with sites in Norfolk, Virginia; Princeton, New Jersey; San Diego, California; and Bowie, Maryland. IDA employees specialize in national security issues, computer software and engineering, strategy and force assessments, operational test and evaluation, research in civil space, expert systems for criminal investigation, and energy and environmental issues. The PwC office in Washington, D.C., has provided audit services to IDA since the early 1960s. The DCAA office in Columbia, Maryland, has provided 0MB Circular A-133 audit services to IDA since FY 1998. PwC and DCAA coordinated and accepted certain audit responsibilities for the FY 2001 single audit of IDA Details on the division of audit responsibilities for the single audit are discussed in Appendix B. As the cognizant Federal agency for IDA, the Office of the inspector General of the Department of Defense (OIG DoD) performed a Quality Control Review (QcR) of the single audit report and supporting audit documentation for the FY 2001 IDA single audit. The objectives of the review were to determine whether the audit was conducted according to generally accepted auditing standards, Government Auditing Standards (GAS), and the auditing and reporting requirements of 0MB Circular A-133. We also reviewed corrective actions taken by PwC as a result of a QCR performed on the FY 1998 single audit of IDA (see OIG DoD Report Number D2OOO-6-OO8, Quality Control Review of PricewaterhouseCoopers LLP, for 0MB Circular A-133 Audit Report for Institute for Defense Analyses, Fiscal Year Ended September 25, 1998," August 14, 2000).