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The transulnar approach (TUA) has been proposed as a safe alternative to the more established transradial approach (TRA) for cardiac catheterization. However, no study has assessed the anatomy and variability of the ulnar artery using angiography.A retrospective analysis of patients who underwent transradial cardiac catheterization during routine clinical care was conducted. Both quantitative and qualitative measurements of artery diameter were collected.Among 700 consecutive patients, mean distal ulnar artery diameter (UAD) was larger in men (3.2 ± 0.9 mm) compared with women (2.7 ± 0.7 mm; P.001). UAD was larger than radial artery diameter (RAD) at all measured sites (distal ulnar, 3.0 ± 0.8 mm; distal radial, 2.9 ± 0.7 mm; P=.046). Compared with the radial artery, the ulnar artery had more atresia (4.3% ulnar vs 0% radial; P.001), fewer loops (0.6% ulnar vs 2.4% radial; P.01), and less spasm (2.7% ulnar vs 23.4% radial; P.001). UAD had more variability (distal variance, 0.68) as compared with the RAD (distal variance, 0.53; P.001).We found that the ulnar artery has a larger diameter, fewer loops, and less spasm, but more variance than the radial artery. Additionally, males have larger ulnar arteries than women. These findings have implications on the application of TUA either as an alternative to TRA or as the primary point of access.

In Ontario, Canada, the Primary Care Collaborative Memory Clinic (PCCMC) model of dementia care provides a team-based assessment and management service that has demonstrated increased capacity for dementia care at the primary care level. PCCMCs are established following completion of a multi-faceted memory clinic training programme. Evidence of the success of this care model has been demonstrated primarily in practice settings with integrated interprofessional healthcare providers (HCPs). Desire to implement PCCMCs in less-resourced family practice settings without integrated interprofessional HCPs has resulted in partnerships with community agencies and services to create the multifaceted teams needed for this care model. The purpose of this study was to describe the key lessons learned in the development and implementation of 18 PCCMCs in primary care practice models without integrated interprofessional HCPs. Mixed methods included tracking of clinic referrals, pre- (N = 122) and post- (N = 71) training surveys to assess practice changes and factors facilitating and challenging clinic implementation. Interviews were conducted with 40 team members to identify key lessons learned. Key enablers were access to training, organisational/ management and care provider support, availability of infrastructure supports and clinic coordination. Data were collected between January 2012 and January 2017. PCCMCs were challenged by a lack of sustainable funding, inadequate infrastructure support, competing priorities, maintaining adequate communication among team members, and coordinating multiple schedules. Suggestions to support longer term sustainability were identified, many addressing identified challenges such as securing sustainable funding, and ensuring partners understand the importance of their role and succession planning. This study demonstrated that by establishing community partnerships and leveraging existing community resources, the PCCMC model is generalisable to multiple family practice settings including those without integrated interprofessional staff. Lessons learned can inform the development of interventions for complex chronic conditions requiring interprofessional support in primary care.

INTRODUCTION: Gastroenterologists at all levels of practice benefit from formal mentoring. Much of the current literature on mentoring in gastroenterology is based on expert opinion rather than data. In this study, we aimed to identify gender-related barriers to successful mentoring relationships from the mentor and mentee perspectives. METHODS: A voluntary, web-based survey was distributed to physicians at 20 academic institutions across the United States. Overall, 796 gastroenterology fellows and faculty received the survey link, with 334 physicians responding to the survey (42% response rate), of whom 299 (90%; 129 women and 170 men) completed mentorship questions and were included in analysis. RESULTS: Responses of women and men were compared. Compared with men, more women preferred a mentor of the same gender (38.6% women vs 4.2% men, P < 0.0001) but less often had one (45.5% vs 70.2%, P < 0.0001). Women also reported having more difficulty finding a mentor (44.4% vs 16.0%, P < 0.0001) and more often cited inability to identify a mentor of the same gender as a contributing factor (12.8% vs 0.9%, P = 0.0004). More women mentors felt comfortable advising women mentees about work-life balance (88.3% vs 63.8%, P = 0.0005). Nonetheless, fewer women considered themselves effective mentors (33.3% vs 52.6%, P = 0.03). More women reported feeling pressured to mentor because of their gender (39.5% vs 0.9% of men, P < 0.0001). Despite no gender differences, one-third of respondents reported negative impact of the COVID-19 pandemic on their ability to mentor and be mentored. DISCUSSION: Inequities exist in the experiences of women mentees and mentors in gastroenterology, which may affect career advancement and job satisfaction.

Background The aim of this study was to clarify the pathophysiology of functional dyspepsia (FD), a highly prevalent gastrointestinal syndrome, and its relationship with the better-understood syndrome of gastroparesis. Methods Adult patients with chronic upper gastrointestinal symptoms were followed up prospectively for 48 weeks in multi-center registry studies. Patients were classified as having gastroparesis if gastric emptying was delayed; if not, they were labeled as having FD if they met Rome III criteria. Study analysis was conducted using analysis of covariance and regression models. Results Of 944 patients enrolled during a 12-year period, 720 (76%) were in the gastroparesis group and 224 (24%) in the FD group. Baseline clinical characteristics and severity of upper gastrointestinal symptoms were highly similar. The 48-week clinical outcome was also similar but at this time 42% of patients with an initial diagnosis of gastroparesis were reclassified as FD based on gastric-emptying results at this time point; conversely, 37% of patients with FD were reclassified as having gastroparesis. Change in either direction was not associated with any difference in symptom severity changes. Full-thickness biopsies of the stomach showed loss of interstitial cells of Cajal and CD206+ macrophages in both groups compared with obese controls. Conclusions A year after initial classification, patients with FD and gastroparesis, as seen in tertiary referral centers at least, are not distinguishable based on clinical and pathologic features or based on assessment of gastric emptying. Gastric-emptying results are labile and do not reliably capture the pathophysiology of clinical symptoms in either condition. FD and gastroparesis are unified by characteristic pathologic features and should be considered as part of the same spectrum of truly "organic" gastric neuromuscular disorders. ClinicalTrials.gov Identifier NCT00398801, NCT01696747

In conjunction with the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the U.S. Food and Drug Administration and the American Pain Society, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society Pain Taxonomy (AAPT) initiative strove to develop the characteristics of a diagnostic system useful for clinical and research purposes across disciplines and types of chronic pain conditions. After the establishment of these characteristics, a working group of clinicians and clinical and basic scientists with expertise in abdominal, pelvic, and urogenital pain began generating core diagnostic criteria and defining the related extraintestinal somatic pain and other symptoms experienced by patients. Systematic diagnostic criteria for several common abdominal, pelvic, and urogenital pain conditions are in development. In this report, we present the proposed AAPT criteria for irritable bowel syndrome (IBS), the most common chronic, noncancer abdominal pain condition. A systematic review and synthesis was conducted to complement the Rome IV Diagnostic Criteria for IBS. Future efforts will subject these proposed AAPT criteria to systematic empirical evaluation of their feasibility, reliability, and validity. The AAPT IBS criteria are part of an evidence-based classification system that provides a consistent vocabulary regarding diagnostic criteria, common features, comorbidities, consequences, and putative mechanisms of the disorder. A similar approach is being applied to other chronic and often debilitating abdominal, pelvic, and urogenital pain conditions. Perspective The AAPT's goal is to develop an evidence-based taxonomy for chronic pain on the basis of a consistently applied multidimensional framework, and encourage experts to apply this taxonomy to specific chronic pain conditions. In this report, the taxonomy is applied to IBS, a chronic abdominal pain condition.

Background Nursing home residents are frail, have multiple medical comorbidities, and are at high risk for delirium. Most of the existing evidence base on delirium is derived from studies in the acute in-patient population. We examine the association between clinical characteristics and medication use with the incidence of delirium during the nursing home stay. Methods This is a retrospective cohort study of 1571 residents from 12 nursing homes operated by a single care provider in Ontario, Canada. Residents were over the age of 55 and admitted between February 2010 and December 2015 with no baseline delirium and a minimum stay of 180 days. Residents with moderate or worse cognitive impairment at baseline were excluded. The baseline and follow-up characteristics of residents were collected from the Resident Assessment Instrument-Minimal Data Set 2.0 completed at admission and repeated quarterly until death or discharge. Multivariate logistic regression was used to identify characteristics and medication use associated with the onset of delirium. Results The incidence of delirium was 40.4% over the nursing home stay (mean LOS: 32 months). A diagnosis of dementia (OR: 2.54, p

Voiding cystourethrogram involves radiation exposure and is invasive. Several guidelines, including the 2011 AAP (American Academy of Pediatrics) guidelines, no longer recommend routine voiding cystourethrogram after the initial urinary tract infection in children. The recent trend in voiding cystourethrogram use remains largely unknown. We examined practice patterns of voiding cystourethrogram use and explored the impact of these guidelines in a single payer system in the past 8 years.We identified all voiding cystourethrograms performed at a large pediatric referral center between January 2008 and December 2015. Patients 2 to 24 months old who underwent an initial voiding cystourethrogram for the diagnosis of a urinary tract infection in the first 6 months of 2009 and 2014 were identified. Medical records were retrospectively reviewed.During the study period 8,422 voiding cystourethrograms were performed and the annual number declined over time. In the pre-AAP and post-AAP cohorts 233 and 95 initial voiding cystourethrograms were performed, respectively. While there was no statistically significant difference in the vesicoureteral reflux detection rate between 2009 and 2014 (37.3% vs 43.0%, p = 0.45), there was a threefold increase in high grade vesicoureteral reflux in 2014 (2.6% vs 8.4%, p = 0.03).A clear trend toward fewer voiding cystourethrograms was noted at our institution. This decrease started before 2011 and cannot be attributed to the AAP guidelines alone. While most detected vesicoureteral reflux remains low grade, there was a greater detection rate of high grade vesicoureteral reflux in 2014 compared to 2009. This may reflect a favorable impact of a more selective approach to obtaining voiding cystourethrograms.

Background High sensitivity cardiac troponin-T (hs-TnT) has been associated with mortality in patients hospitalized with COVID-19. We aimed to determine if hs-TnT levels and their timing are independent predictors of adverse events in these patients. Design Retrospective chart review was performed for all patients hospitalized at our institution between 23 March 2020 and 13 April 2020 who were found to be COVID-19-positive. Clinical, demographic, and laboratory variables including initial and peak hs-TnT were recorded. Univariable and multivariable analyses were completed for a primary composite endpoint of in-hospital death, intubation, need for critical care, or cardiac arrest. Results In the 276 patients analysed, initial hs-TnT above the median (≥17 ng/L) was associated with increased length of stay, need for vasoactive medications, and death, along with the composite endpoint (OR 3.92, p

Background Primary care collaborative memory clinics (PCCMCs) address existing challenges in dementia care by building capacity to meet the needs of persons living with dementia within primary care. This paper describes the strategic implementation of the PCCMC care model in two regions within Ontario. Methods Evaluation of this initiative included the completion of individual interviews (N = 32) with key informants to identify impacts associated with the PCCMCs and tracking of all referrals and assessments completed in the first nine months of clinic implementation. Results The qualitative analysis of interview transcripts generated five major themes: (1) earlier identification of dementia and intervention; (2) increased capacity for dementia care within primary care; (3) better patient and caregiver experience with care; (4) improved continuity, integration and coordination and improved care; and (5) system efficiencies. Across both regions, 925 patients were referred to PCCMCs, of which 631 (68%) had been assessed during the evaluation period. Conclusions Strategic, regional implementation of PCCMCs provides a significant opportunity to support better integrated and coordinated dementia care.

BACKGROUND Symptoms induced by caloric or non-caloric satiety test meals and gastric myoelectrical activity (GMA) have not been studied in patients with diabetic gastroparesis (DGP) before and after intense glucose management. AIMS We determined the effects of continuous subcutaneous insulin infusion (CSII) with continuous glucose monitoring (CGM) on GI symptoms, volume consumed, and GMA induced by the caloric meal satiety test (CMST) and water load satiety test (WLST) in DGP. METHODS Forty-five patients with DGP underwent CMST and WLST at baseline and 24 weeks after CSII with CGM. Subjects ingested the test meals until they were completely full. Visual analog scales were used to quantify pre- and postmeal symptoms, and GMA was recorded with cutaneous electrodes and analyzed visually and by computer. KEY RESULTS: At baseline and 24-week visits, nausea, bloating, abdominal discomfort, and fullness were immediately increased after CMST and WLST (Ps

Many countries are developing primary care collaborative memory clinics (PCCMCs) to address the rising challenge of dementia. Previous research suggests that quality assurance should be a foundational element of an integrated system of dementia care. The purpose of this paper is to understand physicians' and specialists' perspectives on such a system and identify barriers to its implementation.The authors used interviews and a constructivist framework to understand the perspectives on a quality assurance framework for dementia care and barriers to its implementation from ten primary care and ten specialist physicians affiliated with PCCMCs.Interviewees found that the framework reflects quality dementia care, though most could not relate quality assurance to clinical practice. Quality assurance was viewed as an imposition on practitioners rather than as a measure of system integration. Disparities in resources among providers were seen as barriers to quality care. Greater integration with specialists was seen as a potential quality improvement mechanism. Standardized electronic medical records were seen as important to support both quality assurance and clinical care.This work identified several challenges to the implementation of a quality assurance framework to support an integrated system of dementia care. Clinicians require education to better understand quality assurance. Additional challenges include inadequate resources, a need for closer collaboration between specialists and PCCMCs, and a need for a standardized electronic medical record.Greater health system integration is necessary to provide quality dementia care, and quality assurance could be considered a foundational element driving system integration.

Objectives This study examined the utility of prospective radiobrachial angiography (pRBA) in transradial coronary angiography and intervention as a method for reducing procedural complications. Background A growing body of evidence has supported the transradial approach (TRA) as superior to the transfemoral approach (TFA) due to advantages such as reduced bleeding and improved outcomes in high-risk patients. However, TRA has a higher failure rate than TFA, and has seen slow rates of adoption among United States operators. Methods This was a retrospective, single center, case-control analysis of coronary angiography procedures, performed by two experienced operators at the University of Chicago Medical Center between October 28, 2015 and July 21, 2017. Operator 1 began using pRBA during the study, whereas Operator 2 used pRBA in all TRA procedures. There were 567 patients stratified into three groups based on operator and pRBA use. Comparisons of procedural outcomes for Operator 1 before and after adoption of pRBA, and of outcomes between Operator 1 and Operator 2 were made. Results Use of pRBA was associated with reduced overall procedural complication rates (2.5% versus 10.4%, p = 0.004), driven primarily by reflexive radiobrachial angiography (rRBA) after resistance or pain was encountered (8.6% versus 0.0%, p = 0.0001) for Operator 1. A slight reduction in contrast associated with pRBA for Operator 1 was noted, but no difference in procedural time, radiation dose, or additional equipment used across groups was found. No significant difference in adverse procedural outcomes between the pRBA groups of Operator 1 and Operator 2 were observed. In patients with radiobrachial variants in anatomy, use of pRBA was associated with shorter times to cross anatomic lesions, shorter procedure times, reduced use of extra catheters, and less perforations and crossovers compared to patients requiring rRBA. Lack of pRBA was associated with higher procedural complications (hazard ratio 1.08, 95% CI, 1.03–1.13, p = 0.004). Conclusion pRBA may be a useful tool for mitigating procedural complications, reducing time needed to cross difficult radiobrachial anatomy, and reducing the need to utilize additional equipment in TRA. pRBA may offer operators a tool to improve outcomes and increase adoption of this approach.

Many models of safe and effective clinical decision making in medical practice emphasize the importance of recognizing moments of uncertainty and seeking help accordingly. This is not always done effectively, but we know little about what cues prompt health professionals to call on resources beyond their own knowledge or skill set. Such information would offer guidance regarding how systems might be designed to offer better individual support. In this study, the authors explored the situational factors that are present during moments of uncertainty that lead primary care physicians to access external resources. To do so, a generic qualitative exploratory analysis was conducted on 72 narratives collected through audio recorder-based, self-observational, journaling completed by 12 purposively selected family physicians. Participants were asked to provide a detailed descriptive account of the circumstances surrounding their consultation of external resources immediately after 6 sequential patient encounters in which they felt compelled to seek such support. Thematic analysis of the transcripts was performed to better understand participants’ experiences of the social, contextual, and personal features surrounding decisions to seek support. When doing so we observed that specific features of patient encounters were routinely present when physicians decided to access external sources for help. These included medical aspects of the case (e.g., complex presentations), social aspects (e.g., the presence of another individual), and personal factors (e.g., feeling a need for reassurance). External resources were seen as an opportunity for verification, a mechanism to increase patient satisfaction, and a means through which to defend decision-making. Accessing such resources appeared to influence the physician–patient relationship for various reasons. Recognition and further study of the cues that prompt use of external information will further our understanding of physicians’ behavioural responses to challenging/uncertain situations, highlight mechanisms through which a culture of self-directed assessment seeking might be encouraged, and offer guidance regarding ways in which physicians can be encouraged to practice mindfully. Our results make it clear that reasons for which primary care physicians seek the support of external resources may be multifactorial and, therefore, one should be cautious when inferring reasons for the pursuit of such support.

Objectives Changes to the radiographic appearance of the jaws after head and neck radiotherapy have not been thoroughly characterized. This retrospective study examines changes to the appearance of the mandible on panoramic images following intensity-modulated radiotherapy (IMRT) and relates these changes to medical co-morbidities and radiation dose. Study Design The medical and dental charts, and panoramic images of 126 patients who received IMRT at the Princess Margaret Hospital between January 1, 2005, and December 31, 2008, were analyzed independently by three observers. Results Of the 126 patients, 75 (60%) had post-IMRT changes, as seen on panoramic images; most, 66 (88%), consisted of widened periodontal ligament space (WPLS). The median time to WPLS was 29 months after IMRT. Female gender and radiation dose correlated with decreased time to WPLS. Conclusions These results indicate that WPLS is a common radiographic sequela after head and neck radiotherapy, underscoring its clinical significance as a reliable marker of irradiated bone. Furthermore, this type of WPLS needs to be differentiated from odontogenic inflammatory disease and cancer recurrence to avoid unnecessary treatment that may precipitate osteoradionecrosis.

Bothrops asper, a highly venomous pit viper distributed from Colombia and northwestern Peru in South America to southern Mexico, is responsible for most snake bites in Central America, affecting especially young agricultural workers. A 17-year-old male from a rural area in northern Honduras was admitted at San Francisco Hospital after a B. asper bite that had occurred 3 days earlier. The puncture wounds were located on the first toe of the right foot. On the second day of admission, the patient developed dyspnea. A physical examination revealed hypoventilation of the left lung with dullness on 75% of the left lung. Left pleural effusion, approximately 90%, was observed on the chest X-ray. The patient was diagnosed with hemothorax, and a thoracostomy drained 1,350 mL of serosanguineous fluid, followed by the installation of a wet suction control system (Pleur-evac(®)). After 10 days, the patient was discharged. This case illustrates the diversity of hemorrhagic manifestations in envenomations by B. asper.

Aims: To understand persons with dementia (PWD) and care partners’ experiences with the Primary Care Collaborative Memory Clinic (PCCMC) care model. Methods: Interviews were conducted with a purposeful sample of PWD (n = 12) and care partners (N = 16) to identify their perspectives of care received in the clinic and suggestions for improvement. Results: PWD and care partners were satisfied with care received within the PCCMC, had positive interactions with and perceived a strong sense of support from team members and felt listened to; the necessity of cognitive testing was recognized but disliked. Conclusions: The PCCMC care model can address many existing gaps in dementia care as experienced by PWD and care partners.

Background: Proprotein convertase subtilisin/kexin type 9 (PCSK9) is expressed in multiple tissues, including the small intestine. The effect of PCSK9 inhibition on cholesterol absorption is not known. Objectives: Measure serum cholesterol absorption markers before and after initiation of PCSK9 inhibitors. Methods: Single-center retrospective cohort of patients administered evolocumab and alirocumab between July 2015 and January 2017. Paired t tests were used to compare mean serum cholesterol marker concentrations, and ratios to total cholesterol, before and after PCSK9 inhibitor initiation. Analyses were repeated for those taking and not taking statins and taking or not taking ezetimibe at both initiation and follow-up, for each PCSK9 inhibitor, and based on follow-up time (120 days). Results: There were 62 possible participants, 34 were excluded for lack of data or unknown PCSK9 inhibitor initiation date. Average follow-up was 92.5 days. Mean campesterol (before 3.14 μg/mL, 95% CI: 2.79-4.38 μg/mL; after 2.09 μg/mL, 95% CI: 1.87-2.31 μg/mL; P < .0001), sitosterol (before 2.46 μg/mL, 95% CI: 2.23-2.70 μg/mL; after 1.62 μg/mL, 95% CI: 1.48-1.75 μg/mL; P < .0001), and cholestanol (before 3.25 μg/mL, 95% CI: 3.04-3.47 μg/mL; after 2.08 μg/mL, 95% CI: 1.96-2.21 μg/mL; P < .0001) all significantly decreased at follow-up. There was no significant change in absorption marker to total cholesterol ratios. Findings were not influenced by statin or ezetimibe use or nonuse, which PCSK9 inhibitor was prescribed, or time to follow-up. Conclusion: Proprotein convertase subtilisin/kexin type 9 inhibition was associated with decreased cholesterol absorption markers.

Background Transradial coronary angiography/intervention (TRA/TRI) is associated with reduced rates of bleeding, vascular complications, and major adverse cardiovascular events as compared to the transfemoral approach, but remains underutilized in the United States (U.S.). Small radial caliber is often cited as a technical impediment, however radial artery diameter (RAD) has not yet been systematically studied in the U.S. population using routine, prospective radiobrachial angiography . Methods Consecutive patients (pts) with radiobrachial angiography acquired during TRA/TRI from September 2015 to August 2016 were retrospectively analyzed. Quantitative angiography (QA) was performed on digital subtraction angiograms. RAD measurements at distal (dRAD), mid (mRAD), and proximal (pRAD) segments, as well as minimum (minRAD) and maximum (maxRAD) diameters were indexed to radial arterial sheath size and tabulated. RAD measurements were adjudicated by 2 expert operators. Descriptive statistics and regression analyses were performed using STATA (College Station, TX). Results Of 175 radiobrachial angiograms, 2 were excluded due to uninterpretable QA. Woman had smaller RAD versus men: pRAD (3.11 vs 3.33 mm, p = 0.021), minRAD (2.36 vs 2.59 mm, p = 0.006), and maxRAD (3.32 vs 3.53 mm, p = 0.0195). Univariate analysis showed correlation between minRAD and gender ( p = 0.012), age (p = 0.019), and weight (p = 0.008). However, after multivariate analysis , only gender was associated with minRAD ( p = 0.05). Conclusion This is the first study to describe the clinical determinants of RAD using prospective post-vasodilator, radiobrachial angiography in a U.S. population. Women had significantly smaller RAD across proximal, minimum, and maximum segments. Sex was the only multivariate predictor of minRAD.

Preexposure prophylaxis (PrEP) of HIV infection with tenofovir-containing regimens is effective, but plagued by poor adherence in some studies. Options for safe, effective, and acceptable PrEP products, especially for men and women at risk of HIV via receptive anal intercourse (RAI), are needed. We performed a randomized, partially blinded, first-in-human evaluation of four candidate rectal microbicide vehicles-aqueous gel, aqueous fluid, lipid gel, and lipid fluid-to select a prototype for further clinical development. Eight seronegative participants received three doses of each product with each dose separated by at least 2 weeks: one dose was given alone without simulated RAI in clinic, another dose was followed by simulated RAI in clinic, and another dose was self-administered at home in the context of RAI with a partner. Assessments included safety, acceptability, colon histology, ex vivo HIV infectivity of colon tissue explants, and colonic luminal distribution of vehicle and HIV surrogates. Adverse events were all mild and mainly sigmoidoscopy associated. There were minor differences in colon distribution of products and little effect of RAI. Vehicle distribution covered 95% (±7% standard deviation) of the distribution of an HIV surrogate in the colonic lumen. The lipid fluid vehicle increased HIV colon tissue infectability 5-fold [log10 p24 0.68 (95% confidence interval 0.08, 1.28)] and aqueous gel provided 6-fold protection [log10 p24 0.80 (95% confidence interval 0.20, 1.41)] compared to no product baseline. Colon permeability of lipid vehicles was more than 10-fold greater than aqueous vehicles. All products received similar acceptability ratings, though trends favored the gel products. Intensive simultaneous assessment of safety and toxicity, luminal and tissue distribution, ex vivo HIV infectivity, and product acceptability in relevant sexual contexts provided clear differentiation among candidate gels very early in product development. We selected the aqueous gel for further development as a rectal microbicide vehicle.

Recommendations suggest a multicomponent exercise for people with osteoporosis. We identified rehabilitation professionals’ barriers and facilitators to implementing exercise recommendations with people with osteoporosis, and used those to make suggestions for targeted knowledge translation interventions. Future work will report on development and evaluation of the interventions informed by our study. Rehabilitation professionals can help people with osteoporosis to engage in a multicomponent exercise program and perform activities of daily living safely. However, rehabilitation professional face barriers to implementing exercise evidence, especially for specific disease conditions like osteoporosis. We performed a behavioural analysis and identified rehabilitation professionals’ barriers to and facilitators of implementing disease-specific physical activity and exercise recommendations (Too Fit to Fracture recommendations), and used the Behaviour Change Wheel to select interventions. Semi-structured interviews and focus groups were conducted with rehabilitation professionals, including physical therapists, kinesiologists, and occupational therapists, and transcribed verbatim. Two researchers coded data and identified emerging themes. Using the Behaviour Change Wheel framework, themes were categorized into capability, opportunity, and motivation, and relevant interventions were identified. Ninety-four rehabilitation professionals (mean age 40.5 years, 88.3% female) participated. Identified barriers were as follows: capability—lack of training in behaviour change, how to modify recommendations for physical and cognitive impairments; opportunity—lack of resources, time, and team work; motivation—lack of trust between providers, fear in providing interventions that may cause harm. Interventions selected were as follows: education, training, enablement, modelling and persuasion. Policy categories are communication/marketing, guidelines, service provision and environmental/social planning. Key barriers to implementing the recommendations are rehabilitation professionals’ ability to use behaviour change techniques, to modify the recommendations for physical and cognitive limitations and to feel comfortable with delivering challenging but safe interventions for people with osteoporosis, and lacking trust and team work across sectors. Future work will report on development and evaluation of knowledge translation interventions informed by our study.

Normal electrocardiographic (ECG) results have been reported to be associated with a low prevalence of structural heart disease and thus may preclude the need for transthoracic echocardiographic (TTE) imaging. The goal of this study was to determine the prevalence of important TTE abnormalities in patients with a normal ECG referred for TTE imaging.Consecutive electrocardiograms over 6 months were reviewed. Patients with a normal ECG who underwent TTE imaging within 30 days formed the study group. TTE indication and appropriateness designation were determined. TTE findings were noted, including a composite, "major TTE abnormalities" (Maj TTE ABNs).Of 26,254 electrocardiograms reviewed, 3,955 (15%) were normal, 522 with qualifying TTE studies. Maj TTE ABNs were common (27%). The most common TTE indication was signs or symptoms of congestive heart failure (17%), 35% of which had Maj TTE ABNs. Two echocardiographic indications were found to have significantly fewer of Maj TTE ABNs: palpitations (4%, P .01) and preoperative evaluation before noncardiac surgery (6%, P .01). A majority of TTE studies were appropriate (76%), with only 14% rarely appropriate. Maj TTE ABNs were less common in rarely appropriate compared with appropriate TTE studies (13% vs 30%, P .01), with a very low prevalence of Maj TTE ABNs in outpatient rarely appropriate TTE studies (4%).Clinically important TTE abnormalities in patients with a normal ECG are common, suggesting that normal ECG results should not routinely preclude TTE imaging to identify structural heart disease. However, recognition of common clinical indications and application of the appropriate use criteria may identify patients with a normal ECG in whom TTE imaging is of very low yield.

Knowledge exchange with community-dwelling individuals across Ontario revealed barriers to implementation of physical activity recommendations that reflected capability, opportunity, and motivation; barriers unique to individuals with osteoporosis include fear of fracturing, trust in providers, and knowledge of exercise terminology. Using the Behaviour Change Wheel, we identified interventions (training, education, modeling) and policy categories (communication/marketing, guidelines, service provision). Physical activity recommendations exist for individuals with osteoporosis; however, to change behavior, we must address barriers and facilitators to their implementation. The purposes of this project are (1) to identify barriers to and facilitators of uptake of disease-specific physical activity recommendations (2) to use the findings to identify behavior change strategies using the Behaviour Change Wheel (BCW). Focus groups and semi-structured interviews were conducted with community-dwelling individuals attending osteoporosis-related programs or education sessions in Ontario. They were stratified by geographic area, urban/rural, and gender, and transcribed verbatim. Two researchers coded data and identified emerging themes. Using the Behaviour Change Wheel framework, themes were categorized into capability, opportunity, and motivation, and interventions were identified. Two hundred forty community-dwelling individuals across Ontario participated (mean ± SD age = 72 ± 8.28). Barriers were as follows: capability: disease-related symptoms hinder exercise and physical activity participation, lack of exercise-related knowledge, low exercise self-efficacy; opportunity: access to exercise programs that meet needs and preferences, limited resources and time, physical activity norms and preferences; motivation: incentives to exercise, fear of fracturing, trust in exercise providers. Interventions selected were training, education, and modeling. Policy categories selected were communication/marketing, guidelines, and service provision. Barriers unique to individuals with osteoporosis included the following: lack of knowledge on key exercise concepts, fear of fracturing, and trust in providers. Behavior change techniques may need tailoring to gender, age, or presence of comorbid conditions.

Objectives As Asian Americans are dis- proportionately affected by the hepatitis B virus (HBV), we explored predictors of HBV screening and vaccination among Chinese and Korean Americans. Methods We used cross-sectional data from a com- munity-based sample of Chinese Americans (N = 502) and Korean Americans (N = 487) residing in the metropolitan New York City area during 2008-2009. Logistic regression models were stratified by Asian-American subgroup and sex to predict HBV screening (for the entire sam- ple) and HBV vaccination (among those not HBV positive). Results Overall, screening rates were high (71.3% among Chinese and 70.1% among Koreans). The majority of respondents were aware of HBV; however, knowledge about HBV transmission was low. In logistic regression, a physician recommendation was consistently associated with HBV screening and vaccination outcomes across all groups; having heard of HBV was significantly associated with screening and vaccination among Chinese males and screening among Korean males and females. Screening and vaccination barriers were reported among all groups, and included lack of knowledge and feeling well/having no health issues. Conclusions Targeted efforts in these at-risk communities are necessary to improve HBV knowledge, address misinformation about HBV, and eliminate provider-, patient-, and resource-related barriers to HBV screening and vaccination.

Asthmatics have increased risks of common and serious microbial infections including vaccine preventable diseases. Little is known about whether asthma influences waning of humoral immunity. We assessed whether asthma status influences waning of anti-measles virus antibody concentrations over time.The study used a cross-sectional study cohort of healthy children who had been immunized with 1 dose of MMR-II at age approximately 15 months. Between 5 and 12 years of age, measles vaccine virus-specific antibody (IgG) values were measured by enzyme immunoassay and considered seropositive if the enzyme immunoassay index unit was ≥ 1. The medical records were reviewed to determine asthma status during the first 18 years of life by applying predetermined criteria for asthma. A least squares regression model was used to evaluate the effect of asthma status on the relationship between measles antibody titer and time elapsed between the initial measles vaccination and measurement of measles antibody concentrations.Of the 838 eligible children, 281 (34%) met criteria for asthma. Measles antibody waned over time (r = -0.19, P0.001), specifically more rapidly in asthmatics (r = -0.30, P0.001, a decrease of -0.114 unit per year) than non-asthmatics (r = -0.13, P = 0.002, a decrease of -0.046 unit per year; P value for interaction = 0.010). This differential waning rate resulted in a lower mean (SD) measles antibody concentration [1.42 (0.67) vs. 1.67 (0.69), P = 0.008] and lower seropositivity rate (73% vs. 84%, P = 0.038) in asthmatics than non-asthmatics starting around 9.3 years after the initial measles vaccination.Asthma status is associated with waning kinetics of measles antibody among children.

Summary Introduction While voiding cystourethrogram (VCUG) is a widely-accepted test, it is invasive and associated with radiation exposure. Most cases of primary vesicoureteral reflux (VUR) are low-grade and unlikely to be associated with acquired renal scarring. To select patients at greatest risk, in 2011 the American Academy of Pediatrics (AAP) published guidelines for evaluation of children ages 2 - 24 months with urinary tract infections (UTIs). Similarly, in 2010 the Society for Fetal Urology (SFU) published guidelines for patients with hydronephrosis. Herein a prospectively-collected database was queried through the Institute of Clinical Evaluative Sciences (ICES), exploring trends in VCUG ordering within the Ontario Health Insurance Program (OHIP), which guarantees universal access to care. Material and methods A dedicated ICES analyst extracted data on all patients younger than 18 years in Ontario, Canada, with billing codes for VCUG and ICD-9 codes for VUR, from 2004-2014. The baseline characteristics included patient age, gender, geographic region, specialty of ordering provider and previous diagnoses of UTI and/or antenatal hydronephrosis to determine the indication for ordering the test. Of these, patients were subsequently incurred OHIP procedure codes for endoscopic injection or ureteral reimplantation. Patients who had a VCUG in the setting of urethral trauma, posterior urethral valves, and neurogenic bladder were excluded. Results and discussion Trend analysis demonstrated that the total number of VCUGs ordered in the province has decreased over a decade (Figure 1), with a concurrent decrease in VUR diagnosis. On multivariate regression analysis, the decrease in VCUG ordering could not be explained by changes in population demographics or other baseline patient variables. Most VCUGs obtained per year were ordered by pediatricians or family physicians (mean 2,022+523.8), compared with urologists and nephrologists (mean 616+358.3). Interestingly, while the rate of VCUG requests decreased, the annual number of surgeries performed for VUR (endoscopic or open) did not show a significant reduction over time. Conclusions We present a large population-based analysis in a universal access to care system, reporting a decreasing trend in the number of cystograms and differences by primary care versus specialist providers. While it is reassuring to see practice patterns favorably impacted by guidelines, it is also encouraging to note that the number of surgeries has remained stable. This suggests that patients at risk continue to be detected and offered surgical correction. These data confirm previous institution-based assessments and affirm changes in VCUG ordering independent of variables not relevant to the healthcare system, such as the insurance status.

Many patients with gastroparesis have had their gallbladders removed. To determine if clinical presentations of patients with gastroparesis differ in those with prior cholecystectomy compared to patients who have not had their gallbladder removed. Gastroparetic patients were prospectively enrolled in the NIDDK Gastroparesis Registry. Detailed history and physical examinations were performed; patients filled out questionnaires including patient assessment of GI symptoms. Of 391 subjects with diabetic or idiopathic gastroparesis (IG), 142 (36 %) had a prior cholecystectomy at the time of enrollment. Patients with prior cholecystectomy were more often female, older, married, and overweight or obese. Cholecystectomy had been performed in 27/59 (46 %) of T2DM compared to 19/78 (24 %) T1DM and 96/254 IG (38 %) (p = 0.03). Patients with cholecystectomy had more comorbidities, particularly chronic fatigue syndrome, fibromyalgia, depression, and anxiety. Postcholecystectomy gastroparesis patients had increased health care utilization, and had a worse quality of life. Independent characteristics associated with prior cholecystectomy included insidious onset (OR = 2.06; p = 0.01), more comorbidities (OR = 1.26; p

To examine the accuracy of individual Fried frailty phenotype measures in identifying the Fried frailty phenotype in primary care.Retrospective chart review.A community-based primary care practice in Kitchener, Ont.A total of 516 patients 75 years of age and older who underwent frailty screening.Using modified Fried frailty phenotype measures, frailty criteria included gait speed, hand-grip strength as measured by a dynamometer, and self-reported exhaustion, low physical activity, and unintended weight loss. Sensitivity, specificity, accuracy, and precision were calculated for single-trait and dual-trait markers.Complete frailty screening data were available for 383 patients. The overall prevalence of frailty based on the presence of 3 or more frailty criteria was 6.5%. The overall prevalence of individual Fried frailty phenotype markers ranged from 2.1% to 19.6%. The individual criteria all showed sensitivity and specificity of more than 80%, with the exception of weight loss (8.3% and 97.4%, respectively). The positive predictive value of the single-item criteria in predicting the Fried frailty phenotype ranged from 12.5% to 52.5%. When gait speed and hand-grip strength were combined as a dual measure, the positive predictive value increased to 87.5%.There is a need for frailty measures that are psychometrically sound and feasible to administer in primary care. While use of gait speed or grip strength alone was found to be sensitive and specific as a proxy for the Fried frailty phenotype, use of both measures together was found to be accurate, precise, specific, and more sensitive than other possible combinations. Assessing both measures is feasible within primary care.

Guidelines for physical activity exist and following them would improve health. Physicians can advise patients on physical activity. We found barriers related to physicians’ knowledge, a lack of tools and of physician incentives, and competing demands for limited time with a patient. We discuss interventions that could reduce these barriers. Uptake of physical activity (PA) guidelines would improve health and reduce mortality in older adults. However, physicians face barriers in guideline implementation, particularly when faced with needing to tailor recommendations in the presence of chronic disease. We performed a behavioral analysis of physician barriers to PA guideline implementation and to identify interventions. The Too Fit To Fracture physical activity recommendations were used as an example of disease-specific PA guidelines. Focus groups and semi-structured interviews were conducted with physicians and nurse practitioners in Ontario, stratified by type of physician, geographic area, and urban/rural, and transcribed verbatim. Two researchers coded data and identified emerging themes. Using the behavior change wheel framework, themes were categorized into capability, opportunity and motivation, and interventions were identified. Fifty-nine family physicians, specialists, and nurse practitioners participated. Barriers were as follows: Capability–lack of exercise knowledge or where to refer; Opportunity–pragmatic tools, fit within existing workflow, available programs that meet patients’ needs, physical activity literacy and cultural practices; Motivation–lack of incentives, not in their scope of practice or professional identity, competing priorities, outcome expectancies. Interventions selected: education, environmental restructuring, enablement, persuasion. Policy categories: communications/marketing, service provision, guidelines. Key barriers to PA guideline implementation among physicians include knowledge on where to refer or what to say, access to pragmatic programs or resources, and things that influence motivation, such as competing priorities or lack of incentives. Future work will report on the development and evaluation of knowledge translation interventions informed by the barriers.

Celiac disease is triggered by partially digested gluten proteins. Enzyme therapies that complete protein digestion in vivo could support a gluten-free diet, but the barrier to completeness is high. Current options require enzyme amounts on the same order as the protein meal itself. In this study, we evaluated proteolytic components of the carnivorous pitcher plant (Nepenthes spp.) for use in this context. Remarkably low doses enhance gliadin solubilization rates and degrade gliadin slurries within the pH and temporal constraints of human gastric digestion. Potencies in excess of 1200:1 (substrate-to-enzyme) are achieved. Digestion generates small peptides through nepenthesin and neprosin, the latter a novel enzyme defining a previously-unknown class of prolyl endoprotease. The digests also exhibit reduced TG2 conversion rates in the immunogenic regions of gliadin, providing a twin mechanism for evading T-cell recognition. When sensitized and dosed with enzyme-treated gliadin, NOD/DQ8 mice did not show intestinal inflammation, when compared to mice challenged with only pepsin-treated gliadin. The low enzyme load needed for effective digestion suggests that gluten detoxification can be achieved in a meal setting, using metered dosing based on meal size. We demonstrate this by showing efficient antigen processing at total substrate-to-enzyme ratios exceeding 12,000:1.

Summary Introduction Ileocystoplasty is the standard technique used for bladder augmentation, and has been used widely for decades. However, it is known to be associated with complications such as stone formation, mucus production, metabolic acidosis, urinary tract infections, intestinal obstruction, and a long-term risk of bladder cancer. Seromuscular bladder augmentation (SMBA) is an alternative to the standard ileocystoplasty, and has been associated with a lower incidence of bladder stones. Few reports have been published on intermediate outcomes of SMBA. Herein, we report long-term outcomes of SMBA from a single institution compared with standard ileocystoplasty. Methods After Institutional Review Board approval, a retrospective chart review of all patients who underwent bladder augmentation at our institution over a 14-year period was performed. The status of patients after SMBA (10 patients) was compared according to age, sex, and diagnosis with patients who underwent traditional ileocystoplasty (30 patients). Parameters such as demographic information, pre- and postoperative bladder capacity as assessed by urodynamic studies, urinary tract infections (UTIs), bladder calculi, incontinence, need for secondary surgical procedures, and spontaneous bladder perforation were compared in the two groups. All the patients were on a clean intermittent catheterization (CIC) regimen. Results Over the study period, 10 patients underwent SMBA and 30 patients (according to age, sex, and diagnosis) underwent standard ileocystoplasty; the average age at surgery was 10.3 and 10 years respectively, with a mean follow up of 6.7 years in the SMBA group and 6 years in the ileocystoplasty group. There were no statistically significant differences in the rate of UTIs, urinary incontinence, subsequent surgery, or spontaneous bladder perforation. The mean bladder capacity increased significantly for both groups as assessed by pre- and postoperative urodynamic studies, although the difference in the rate of bladder calculi between the two groups (0 [0%] vs. 8 [27%], p = 0.06) did not reach statistical significance ( Table ). Conclusions SMBA is safe and efficacious and may result in a lower rate of stone formation than standard ileocystoscopy. SMBA should be considered as a viable alternative to standard ileocystoplasty Table . Outcome comparison: SMBA versus standard ileocystoplasty. SMBA (n = 10) Ileocystoplasty (n = 30) p Mean preoperative bladder capacity, mL (nA = 8, nB = 19) 121 ± 93 153 ± 130 0.26 Mean postoperative bladder capacity, mL (nA = 4, nB = 14) 400 ± 241 378 ± 153 0.42 Mean time of postoperative urodynamics 51 ± 44 50 ± 28 0.47 Urinary tract infections 3 (30%) 8 (27%) 0.8 Bladder calculi 0 (0%) 8 (27%) 0.06 Incontinence 2 (20%) 11 (37%) 0.3 Spontaneous bladder perforation 1 (10%) 0 (0%) 0.07 Secondary surgery 1 (10%) 7 (23%) 0.4 Re-do augmentation 0 (0%) 2 (7%) Stone surgery 0 (0%) 5 (17%) Bladder rupture repair 1 (10%) 0 (0%) .

Objective: To assess a quality improvement initiative aimed at minimizing door-to-balloon (DTB) times for ST-elevation myocardial infarction (STEMI) patients presenting without chest pain. Background: Timely percutaneous coronary intervention (PCI) is the cornerstone of STEMI care. The absence of chest pain delays PCI. Improvements in DTB times may need to focus on atypical presentation patients. Methods: We compared DTB times on all STEMI patients admitted through the emergency department who underwent PCI before (Phase I; October 2004–June 2007) and after (Phase II; July 2007–October 2009) the quality improvement effort, which mandated rapid electrocardiogram (ECG) triage for an expanded list of presenting symptoms. Results: In Phase I (69 patient, 60 with chest pain), patients with chest pain had a shorter mean time to first ECG (ECG Interval) by 32.0 min (P < 0.01) and nonsignificantly faster mean DTB time by 42.0 min (P = 0.07) compared to patients who presented without chest pain. In Phase II (62 patients, 56 with chest pain) compared to Phase I, mean ECG interval decreased by 44 min (P = 0.02) and mean DTB time by 99 min (P = 0.01) in patients without chest pain, eliminating the differences in ECG intervals between typical and atypical presentations (12 min vs. 11 min, P = 0.91). Multivariable analysis controlling for on/off hours and patient characteristics confirmed these findings. Conclusions: A simple modification of emergency room ECG triage protocol, which expands indications for rapid ECG performance, was successful in improving rapid reperfusion for patients with STEMI presenting without chest pain. © 2011 Wiley-Liss, Inc.

Background The treatment of cancer in patients with comorbidities can be challenging as these individuals are underrepresented in clinical trials. We conducted a systematic review to determine the impact of comorbidity on chemotherapy use, delivery, tolerability, and survival among patients with solid tumors to summarize current data and provide recommendations for future research. Methods All English-language articles from 1990 to 2009 that explored the association between comorbidity and chemotherapy were identified from MEDLINE and EMBASE. Abstracts were reviewed for eligibility, and data on study design and results were extracted. Results Thirty-four articles met the inclusion criteria. Study populations and design were heterogeneous, and the quality of reporting was generally poor. Most studies were retrospective (76%), were based on a cancer registry linked with administrative data (47%), and assessed the overall effect of comorbidity using an index score (76%). Sixteen studies (47%) investigated chemotherapy use, and 29 (85%) addressed survival. The majority reported decreased chemotherapy use (75%) and inferior survival (69%) for patients with comorbidities compared to those without. In 11 of 14 studies, inferior survival was independent of treatment. Of the few studies that addressed chemotherapy tolerability, seven of 10 reported an increased rate of severe toxicity, and three of five reported increased treatment delays for patients with comorbidity. Conclusion Chemotherapy use and outcomes among cancer patients with comorbidities are generally inferior, but the existing evidence is limited and of insufficient quality to determine the relationship between decreased use and inferior survival. Further studies that are prospective and site and stage specific are warranted.

Objective Five of 400 starters of the 2009 Western States Endurance Run (WSER) were hospitalized with hyponatremia and rhabdomyolysis. This article explores the risk factors associated with development of hyponatremia and rhabdomyolysis. Methods Data on the 5 cases were collected retrospectively from the runners and medical records, and all race participants were invited to complete a post-race survey. Characteristics of the cases were compared with the other race participants. Results The 5 runners developing hyponatremia with rhabdomyloysis were men with a mean (±SD) age of 39 ± 7 years. Presenting complaints included neurological symptoms among 3 and nausea among 3. Compared with those runners not developing hyponatremia with rhabdomyolysis, the cases tended to be younger, faster, more likely to have sustained an injury which interfered with training prior to the race, and were more likely to use nonsteroidal anti-inflammatory drugs (NSAIDs) during the race. The 3 of 5 cases progressing to acute renal failure were characterized by higher initial blood urea nitrogen (BUN; 43–69 vs 18–23 mg/dL) and creatinine (2.8–4.9 vs 1.1–1.2 mg/dL) levels but were not distinguished by creatinine phosphokinase (CPK) concentrations. Conclusions Over 1% of participants in the 2009 WSER were hospitalized with hyponatremia in combination with rhabdomyolysis. These individuals tended to be younger, faster, more likely to have had an injury that interfered with training, and more likely to have used NSAIDs during the race. Higher initial BUN and creatinine levels, but not CPK concentrations, distinguished those 3 who progressed to acute renal failure.

Summary Introduction There is a paucity of data comparing urethral stents after hypospadias repair. The aim of this study is to compare Silastic tubing vs Koyle stents (Cook Medical), addressing outcomes related to stent-related complications, added visits to healthcare providers in the early postoperative period, and postoperative complications at clinic follow-up. Materials and methods Following an alternate week allocation, 150 patients were prospectively assigned to have Silastic tubes (n = 76) and Koyle stents (n = 74) after hypospadias repair. Exclusion criteria included fistula repairs, drainage via alternative catheter, or stentless repairs. Silastic tubes were secured with 5–0 Prolene and removed during a planned clinic visit. Koyle stents were secured with 7–0 PDS and left to fall out spontaneously. Questionnaires capturing postoperative outcomes were completed. Results and discussion Median age was 13 and 11 months in the Silastic and Koyle stent groups, respectively (P = 0.48). There was no statistically significant difference in hypospadias location. Blockage/kinking of stents occurred in 8% (n = 6) of the Silastic and 9% (n = 7) Koyle stent groups, P = 0.78. Although follow-up was short, there was no difference in fistula rate among the Silastic (21%, n = 14) versus Koyle stent group (17%, n = 11), P = 0.66. There was a twofold higher rate of emergency department (ED) visits in the Silastic (32%, n = 24) versus Koyle stent group (16%, n = 12), P = 0.03. Half of ED visits in the Silastic group were related to stents falling out before planned removal. The authors propose that Silastic stents falling out before the removal date may have led to increased parental anxiety and thus a visit to the ED. With improved parental education, the authors propose that many of these visits may have been preventable. Conclusions There were no significant differences in stent-related complications or fistula rate between the Silastic and Koyle stent groups. Although there were a twofold higher number of visits to the ED in the Silastic stent group, the authors propose that this was due to parental education rather than the stent itself. Table . Primary and secondary outcomes. Silastic tubing (n = 76) Koyle stent (n = 74) P-value Stent-related events Blockage/kinking 6 (8%) 7 (9%) 0.78 Tearing 0 0 1.00 Visits to healthcare provider in the early postoperative period Emergency department 24 (32%) 12 (16%) 0.03 Outpatient clinic 52 (68%) 38 (51%) 0.04 Fistulas/dehiscence at clinic follow-up a 14 (21%) 11 (17%) 0.66 a Excludes patients lost to follow-up.

Background: Physicians often find significant challenges in assessing automobile driving in persons with mild cognitive impairment and mild dementia and deciding when to report to transportation administrators. Care must be taken to balance the safety of patients and other road users with potential negative effects of issuing such reports. Objective: The aim of this study was to assess whether a computer-based Driving in Dementia Decision Tool (DD-DT) increased appropriate reporting of patients with mild dementia or mild cognitive impairment to transportation administrators. Methods: The study used a parallel-group cluster nonblinded randomized controlled trial design to test a multifaceted knowledge translation intervention. The intervention included a computer-based decision support system activated by the physician-user, which provides a recommendation about whether to report patients with mild dementia or mild cognitive impairment to transportation administrators, based on an algorithm derived from earlier work. The intervention also included a mailed educational package and Web-based specialized reporting forms. Specialists and family physicians with expertise in dementia or care of the elderly were stratified by sex and randomized to either use the DD-DT or a control version of the tool that required identical data input as the intervention group, but instead generated a generic reminder about the reporting legislation in Ontario, Canada. The trial ran from September 9, 2014 to January 29, 2016, and the primary outcome was the number of reports made to the transportation administrators concordant with the algorithm. Results: A total of 69 participating physicians were randomized, and 36 of these used the DD-DT; 20 of the 35 randomized to the intervention group used DD-DT with 114 patients, and 16 of the 34 randomized to the control group used it with 103 patients. The proportion of all assessed patients reported to the transportation administrators concordant with recommendation did not differ between the intervention and the control groups (50% vs 49%; Z=−0.19, P=.85). Two variables predicted algorithm-based reporting—caregiver concern (odds ratio [OR]=5.8, 95% CI 2.5-13.6, P

Background. Chronic Obstructive Pulmonary Disease (COPD) is underdiagnosed in primary care.Aim. To explore the utility of proactive identification of COPD in patients 75 years of age and older in a Canadian primary care setting.Methods.Canadian Thoracic Society (CTS) screening questions were administered to patients with a smoking history of 20 pack-years or more; those with a positive screen were referred for postbronchodilator spirometry.Results. A total of 107 patients (21%), of 499 screened, had a 20-pack-year smoking history; 105 patients completed the CTS screening. Forty-four (42%) patients were positive on one or more questions on the screening; significantly more patients with a previous diagnosis of COPD (64%) were positive on the CTS compared to those without a previous diagnosis of COPD (30%). Of those who were not previously diagnosed with COPD (N= 11), four (36%) were newly diagnosed with COPD.Conclusion. A systematic two-stage method of screening for COPD, using CTS screening questions followed by spirometric confirmation, is feasible in the context of a busy primary care setting. More research is needed to assess the value of restricting screening to patients with a smoking history of 20 pack-years and on the sensitivity and specificity of these measures.

Students training to be educators frequently exhibit voice disorders prior to employment. To date, there exist no similar studies of future speech-language pathologists (SLPs). The study is designed as a prospective, nonrandomized survey. The objective of this study is to determine the voice problems of first year graduate students training to be SLPs. Participants were 104 first year graduate students majoring in speech-language pathology at two universities. The Quick Screen for Voice was administered. Participants who failed completed a questionnaire regarding voice problems, medical history, daily habits, and voice use. When responses further indicated voice-related problems, endoscopic examination was completed. Fourteen percent (N=15) of the participants failed the screening by demonstrating two or more abnormal voice characteristics. These included persistent glottal fry (present in all who failed), low habitual pitch, juvenile resonance, hoarse, breathy, or strained phonation, abnormally low pitch on sustained vowels, and voice breaks during the frequency range. Twelve percent (N=12) failed both the screening and follow-up questionnaire. Responses included self-reported dysphonia, medical history with voice-related side effects, difficulty with excessive voice use, and voice problems occurring daily or weekly. Endoscopic evaluation showed one participant with bilateral vocal nodules. The results suggest that voice problems among future SLPs (12%) are more common than the 3-9% reported in the general population and similar to the 11% previously reported for teachers. However, future SLP voice problems are less frequent than those reported among education majors (21%) and all college students (17%). Faculty should identify students with voice problems and emphasize optimal voice use in classroom and clinical settings.

Summary Objective Surgeons who perform pediatric laryngotracheal reconstruction (LTR) have traditionally measured outcomes based on successful airway restoration. Additional information regarding post-surgical vocal function may help guide outcomes toward optimal voice. This investigation documented the relationship between the site of vocal tract vibratory source (glottic versus supraglottic versus mixed) and vocal function in children following LTR. Methods Endoscopic evaluation of voice source was completed in 16 participants who had LTR as children. Three judges rated vocal quality using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Acoustic analysis was completed to obtain fundamental frequency and determine the periodicity of the vibratory signal. Results Seven participants were identified to have glottic vibration and nine had supraglottic or mixed-source vibration for voice. All participants were rated as having some degree of voice disorder. Those who used primarily supraglottic/mixed phonation exhibited significantly worse overall severity, roughness, and pitch deviance ratings than did those who used primarily glottic phonation. Significant differences in strain were also noted; however, poor inter-rater reliability rating of strain confounded this result. No significant differences in breathiness or loudness ratings were exhibited. Periodic vibration was observed in 10 of 16 participants (5 of 7 in the glottic group and 5 of 9 in the supraglottic/mixed group). Three of the five participants who had periodic supraglottic phonation had fundamental frequency measures ( F 0 ) that were below normative ranges, 1 approximated normal, and 1 was above normal range. Two of the five participants who had periodic glottic phonation had lower than expected F 0 s, 1 was within normal range, and 2 were high. Conclusions As observed in earlier studies, voices produced with supraglottic phonation were generally less acceptable than those with glottic phonation. However, phonation with supraglottic structures yielded highly variable voice that may be amenable to change. Some children achieved periodic vibration with alternate structures, suggesting inherent flexibility and adaptability in the tissues used to make sound.

Women comprise 19% of the American Gastroenterological Association (AGA) membership. We performed a prospective study to determine whether female gastroenterologists were less likely to achieve career advancement and satisfaction.We administered an online survey to AGA members from 2004-2006. The survey contained questions regarding effects of gender on career advancement, satisfaction with career, promotional policies, and integration of family and career.A total of 457 individuals (response rate 9% after 2 major invitations) completed the survey, including 262 (57%) women (20% in private practice, 53% in academic careers, and 27% trainees) and 195 men (23% in private practice, 58% in academic careers, and 19% trainees). The male gastroenterologists were significantly older (P.005) and in their careers for significantly more years (P = .002). There were no significant differences with respect to marital status, number of children, or number of hours worked between the genders. Men were more likely to achieve the rank of full professor (P = .035), and significantly more women reported that gender affected their career advancement (47% vs 9%; P.001). Women in academic careers reported less satisfaction with their careers (P = .01) and perceived more difficulty in achieving promotion and tenure. Women were more likely to choose private practice careers because of part-time options (P = .025). Equal numbers of men and women in practice reported difficulty balancing work and family life.Significantly more female than male gastroenterologists perceive that gender has affected their career advancement. Female academic gastroenterologists reported less overall career satisfaction and promotion than male academic gastroenterologists.

Summary Objective: To determine inter- and intrajudge agreement in rating signs of laryngopharyngeal reflux (LPR) under “ideal” conditions: Experienced coworkers in a practice devoted to voice-disordered patients, raters trained in the items on a standardized scale, raters from both speech-language pathology (SLP) and otolaryngology, and raters of asymptomatic participants. Study Design: Prospective study using a scale to rate videolaryngoscopic examinations. Methods: Two SLPs and two otolaryngologists used the Reflux Finding Scale (RFS) to independently rate videotapes of endoscopic examinations for 30 participants asymptomatic of reflux. Results: Thirteen (43%) were assigned a total score >7, indicative of LPR, by at least one rater. Intraclass correlation coefficients showed a significant lack of agreement in total scores provided by the otolaryngologists and by all raters combined. One otolaryngologist and the two SLPs demonstrated good interrater agreement in total scores. McNamar's statistic and Poisson regression modeling showed differences in rater agreement for many individual items. Repeated ratings of four participants showed no significant differences, indicating good intrarater reliability. Conclusions: Level of rater agreement regarding the presence and the severity of physical findings attributed to LPR within and between otolaryngologists and SLPs differed. Given the role each profession plays in the diagnosis and treatment of LPR and related voice disturbances, higher levels of interprofessional agreement are desired. Results support the need for greater consensus among professionals regarding the discreet features of physical findings associated with LPR, a fuller understanding of normal variants, and greater emphasis on interrater reliability when rating physical findings.

To explore correlates of meeting recommended physical activity (PA) goals among middle-aged and older Korean Americans at risk for diabetes mellitus (DM).PA patterns and their correlates were assessed among 292 middle-aged and older Korean Americans at risk for DM living in New York City using cross-sectional design of baseline information from a diabetes prevention intervention. PA was assessed by self-report of moderate and vigorous activity, results were stratified by age group (45-64 and 65-75 years), and bivariate analyses compared individuals performing less than sufficient PA and individuals performing sufficient PA. Logistic regression was used to calculate adjusted odds ratios predicting sufficient PA.After adjusting for sex, age group, years lived in the United States, marital status, health insurance, and body mass index (BMI), sufficient PA was associated with male sex, older age, lower BMI, eating vegetables daily, and many PA-specific questions (lack of barriers, confidence, and engagement). When stratified by age group, male sex and eating vegetables daily was no longer significant among Koreans 65 to 75 years of age, and BMI was not significant for either age group.PA interventions targeting this population may be beneficial and should consider the roles of sex, age, physical and social environment, motivation, and self-efficacy.Clinical providers should understand the unique motivations for PA among Korean Americans and recognize the importance of culturally driven strategies to enable lifestyle changes and support successful aging for diverse populations.

OBJECTIVES The purpose of this study was to determine qualitative pancreatic magnetic resonance imaging (MRI) features that must be present to predict abnormal pancreatic secretory function in patients evaluated for chronic pancreatitis (CP). METHODS The MRIs of study subjects were reviewed by 2 abdominal radiologists; qualitative parenchyma and ductal features were recorded. Endoscopic pancreatic function test (ePFT) results (reference standard) were classified as normal (peak pancreatic fluid bicarbonate [HCO3-] ≥75 meq/L) or abnormal (

Background & Aims Gastroparesis is a chronic clinical syndrome characterized by delayed gastric emptying. However, little is known about patient outcomes or factors associated with reduction of symptoms. Methods We studied adult patients with gastroparesis (of diabetic or idiopathic type) enrolled in the National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Clinical Research Consortium Gastroparesis Registry, seen every 16 weeks and treated according to the standard of care with prescribed medications or other therapies at 7 tertiary care centers. Characteristics associated with reduced symptoms, based on a decrease of 1 or more in the gastroparesis cardinal symptom index (GCSI) score after 48 weeks of care, were determined from logistic regression models. Data were collected from patients for up to 4 years (median, 2.1 y). Results Of 262 patients, 28% had reductions in GCSI scores of 1 or more at 48 weeks. However, there were no significant reductions in GCSI score from weeks 48 through 192. Factors independently associated with reduced symptoms at 48 weeks included male sex, age 50 years and older, initial infectious prodrome, antidepressant use, and 4-hour gastric retention greater than 20%. Factors associated with no reduction in symptoms included overweight or obesity, a history of smoking, use of pain modulators, moderate to severe abdominal pain, a severe gastroesophageal reflex, and moderate to severe depression. Conclusions Over a median follow-up period of 2.1 years, 28% of patients treated for gastroparesis at centers of expertise had reductions in GCSI scores of 1 or greater, regardless of diabetes. These findings indicate the chronic nature of gastroparesis. We identified factors associated with reduced symptoms that might be used to guide treatment. ClinicalTrials.gov no: NCT00398801.

Learning and memory and the underlying cellular correlate, long-term synaptic plasticity, involve regulation by posttranslational modifications (PTMs). Here we demonstrate that conjugation with the small ubiquitin-like modifier (SUMO) is a novel PTM required for normal synaptic and cognitive functioning. Acute inhibition of SUMOylation impairs long-term potentiation (LTP) and hippocampal-dependent learning. Since Alzheimer's disease (AD) prominently features both synaptic and PTM dysregulation, we investigated SUMOylation under pathology induced by amyloid-β (Aβ), a primary neurotoxic molecule implicated in AD. We observed that SUMOylation is dysregulated in both human AD brain tissue and the Tg2576 transgenic AD mouse model. While neuronal activation normally induced upregulation of SUMOylation, this effect was impaired by Aβ42 oligomers. However, supplementing SUMOylation via transduction of its conjugating enzyme, Ubc9, rescued Aβ-induced deficits in LTP and hippocampal-dependent learning and memory. Our data establish SUMO as a novel regulator of LTP and hippocampal-dependent cognition and additionally implicate SUMOylation impairments in AD pathogenesis.

To explore the barriers to and facilitators of adapting and expanding a primary care memory clinic model to integrate care of additional complex chronic geriatric conditions (heart failure, falls, chronic obstructive pulmonary disease, and frailty) into care processes with the goal of improving outcomes for seniors.Mixed-methods study using quantitative (questionnaires) and qualitative (interviews) methods.Ontario.Family physicians currently working in primary care memory clinic teams and supporting geriatric specialists.Family physicians currently working in memory clinic teams (n = 29) and supporting geriatric specialists(n = 9) were recruited as survey participants. Interviews were conducted with memory clinic lead physicians (n = 16).Statistical analysis was done to assess differences between family physician ratings and geriatric specialist ratings related to the capacity for managing complex chronic geriatric conditions, the role of interprofessional collaboration within primary care, and funding and staffing to support geriatric care. Results from both study methods were compared to identify common findings.Results indicate overall support for expanding the memory clinic model to integrate care for other complex conditions. However, the current primary care structure is challenged to support optimal management of patients with multiple comorbidities, particularly as related to limited funding and staffing resources. Structured training, interprofessional teams, and an active role of geriatric specialists within primary care were identified as important facilitators.The memory clinic model, as applied to other complex chronic geriatric conditions, has the potential to build capacity for high-quality primary care, improve health outcomes,promote efficient use of health care resources, and reduce healthcare costs.

Green fluorescent protein (GFP) expression was evaluated in tissues of different transgenic rodents—Sprague-Dawley (SD) rat strain [SD-Tg(GFP)Bal], W rat strain [Wistar-TgN(CAG-GFP)184ys], and M mouse strain [Tg(GFPU)5Nagy/J]—by direct fluorescence of native GFP expression and by immunohistochemistry. The constitutively expressing GFP transgenic strains showed tissue-specific differences in GFP expression, and GFP immunohistochemistry amplified the fluorescent signal. The fluorescence of stem/progenitor cells cultured as neurospheres from the ependymal region of the adult spinal cord from the GFP SD and W rat strains was assessed in vitro. After transplantation of the cells into wildtype spinal cord, the ability to track the grafted cells was evaluated in vivo. Cultured stem/progenitor cells from the SD strain required GFP immunostaining to be visualized. Likewise, after transplantation of SD cells into the spinal cord, immunohistochemical amplification of the GFP signal was required for detection. In contrast, GFP expression of stem/progenitor cells generated from the W strain was readily detected by direct fluorescence both in vitro and in vivo without the need for immunohistochemical amplification. The cultured stem/progenitor cells transplanted into the spinal cord survived for at least 49 days after transplantation, and continued to express GFP, demonstrating stable expression of the GFP transgene in vivo.

Chronic arsenic toxicity occurs primarily through inadvertent ingestion of contaminated water and food or occupational exposure, but it can also occur through medicinal ingestion. This case features a 53-year-old lifetime nonsmoker with chronic asthma treated for 10 years in childhood with Chinese traditional medicine containing arsenic. The patient was diagnosed with Bowen’s disease and developed extensive-stage small-cell carcinoma of the lung 10 years and 47 years, respectively, after the onset of arsenic exposure. Although it has a long history as a medicinal agent, arsenic is a carcinogen associated with many malignancies including those of skin and lung. It is more commonly associated with non–small-cell lung cancer, but the temporal association with Bowen’s disease in the absence of other chemical or occupational exposure strongly points to a causal role for arsenic in this case of small-cell lung cancer. Individuals with documented arsenic-induced Bowen’s disease should be considered for more aggressive screening for long-term complications, especially the development of subsequent malignancies.

Summary The purpose of the present study was to examine the effect of prolonged loud reading, intended to induce fatigue, on vocal function in adults with unilateral vocal fold paralysis (UVFP). Subjects were 20 adults, 37–60 years old, with UVFP secondary to recurrent laryngeal nerve paralysis. Subjective ratings and instrumental measures of vocal function were obtained before and after reading. Statistical analysis revealed subjects rated their vocal quality and physical effort for voicing more severely following prolonged loud reading, whereas expert raters did not detect a significant perceptual difference in vocal quality. Reading fundamental frequency (Fo) was significantly increased following prolonged loud reading, as were mean airflow rates at all pitch conditions. Maximum phonation times for comfort and low pitches significantly decreased during posttests. Multiple regression analyses revealed significant associations between ratings of posttest physical effort and select posttest measures. Interpretation of results indicates the prolonged loud reading task was successful in vocally fatiguing most of the UVFP subjects. Key physiologic correlates of vocal fatigue, in individuals with UVFP, include further reduction of glottic efficiency, resulting in decreased regulation of glottic airflow and a temporary destabilization of speaking fundamental frequency.

RÉSUMÉLa mise en oeuvre en l’Ontario de 15 cliniques interprofessionnelles des troubles de la mémoire à base de soins primaires représente un modèle unique de gestion de cas en équipe, visant à accroître la capacité de traitement de la démence au niveau des soins primaires. Chaque clinique a suivi les patients; dans un sous-ensemble des cliniques, des graphiques ont été vérifiés par les gériatres, les membres de la clinique ont été interrogés, et les patients, les soignants et les médecins traitants ont rempli des questionnaires de satisfaction. Dans toutes les cliniques, 582 patients ont été évalués, et 8,9 pour cent ont été adressés à un spécialiste. Les patients et les soignants étaient très satisfaits des soins reçus, de même que les médecins traitants de la famille, qui ont déclaré une augmentation de la capacité à gérer la démence. La vérification des dossiers des gériatres a révélé un niveau élevé d'accord avec le diagnostic et la gestion. Cette étude a démontré l'acceptabilité, la faisabilité et l'efficacité préliminaire du modèle de clinique des troubles de la mémoire de soins primaires. Dirigée par les médecins de famille spécialement formés, il a fourni un accès en temps opportun à la haute qualité des soins de la démence collaboratives, affectant recours aux services de santé par une utilisation plus efficace des maigres ressources spécialisées en gériatrie.

Background Current treatment of diffuse-large-B-cell lymphoma (DLBCL) includes rituximab, an expensive drug, combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy. Economic models have predicted rituximab plus CHOP (RCHOP) to be a cost-effective alternative to CHOP alone as first-line treatment of DLBCL, but it remains unclear what its real-world costs and cost-effectiveness are in routine clinical practice. Methods We performed a population-based retrospective cohort study from 1997 to 2007, using linked administrative databases in Ontario, Canada, to evaluate the costs and cost-effectiveness of RCHOP compared to CHOP alone. A historical control cohort (n = 1,099) with DLBCL who received CHOP before rituximab approval was hard-matched on age and treatment intensity and then propensity-score matched on sex, comorbidity, and histology to 1,099 RCHOP patients. All costs and outcomes were adjusted for censoring using the inverse probability weighting method. The main outcome measure was incremental cost per life-year gained (LYG). Results Rituximab was associated with a life expectancy increase of 3.2 months over 5 years at an additional cost of $16,298, corresponding to an incremental cost-effectiveness ratio of $61,984 (95% CI $34,087‒$135,890) per LYG. The probability of being cost-effective was 90% if the willingness-to-pay threshold was $100,000/LYG. The cost-effectiveness ratio was most favourable for patients less than 60 years old ($31,800/LYG) but increased to $80,600/LYG for patients 60–79 years old and $110,100/LYG for patients ≥80 years old. We found that post-market survival benefits of rituximab are similar to or lower than those reported in clinical trials, while the costs, incremental costs and cost-effectiveness ratios are higher than in published economic models and differ by age. Conclusions Our results showed that the addition of rituximab to standard CHOP chemotherapy was associated with improvement in survival but at a higher cost, and was potentially cost-effective by standard thresholds for patients