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To determine whether central findings from vestibular tests predict abnormal findings on magnetic resonance imaging.
This study was a retrospective case series at a tertiary referral centre. The main outcome measure of this diagnostic intervention study was the positive predictive value of central vestibular findings in relation to magnetic resonance imaging abnormalities.
Central vestibular findings had a 50.9 per cent positive predictive value for magnetic resonance imaging abnormalities across all age groups although they varied according to age group. Optokinetic nystagmus (p < 0.05) and abnormal findings on videonystagmography tests (p < 0.05) were the main predictors of magnetic resonance imaging abnormalities. White matter lesions constituted the bulk of the central lesions on magnetic resonance imaging followed by cortical and cerebellar atrophy.
Central vestibular findings had a 50.9 per cent positive predictive value for magnetic resonance imaging abnormalities across all age groups. Magnetic resonance imaging is medically justified to further evaluate patients with central findings on vestibular studies. Therefore, it is reasonable to request magnetic resonance imaging in these patients.
OBJECTIVES/SPECIFIC AIMS: In a randomized controlled trial in participants with HIV infection, recombinant human growth hormone (rhGH) reduced visceral adipose tissue (VAT); addition of rosiglitazone to rhGH prevented the accompanying decline in insulin sensitivity (SI). Within this parent RCT, we sought to determine the effect of rosiglitazone and rhGH intervention on alpha-1-acid glycoprotein (AGP), a biomarker of inflammation. We also investigated AGP as an independent risk factor for SI and VAT changes along with any potential effect modification by AGP of the intervention. METHODS/STUDY POPULATION: Participants with HIV-infection (n = 72) with abdominal adiposity and insulin resistance were randomized to rosiglitazone, rhGH, combination, or placebo for 12 weeks (NCT00130286). SI was determined by frequently sampled intravenous glucose tolerance test, and VAT by whole body MRI. AGP concentrations were determined by immunoturbidimetric assay in available serum samples at baseline (time 0), 4, and 12 weeks (n = 41 participants with samples at all 3 time points). A linear mixed model was used to assess the impact of intervention over time on AGP concentrations. General linear models were used to assess baseline AGP concentrations as an independent predictor of SI and VAT changes by treatment group with the model initially including age quartile, gender, race, ethnicity, BMI, HIV RNA <400 copies/mL, antiretroviral regimen, CD4 count, Stavudine use, and zidovudine use with step-by-step removal of least significant predictors. Effect modification was assessed by adding an interaction term between AGP and assigned intervention. RESULTS/ANTICIPATED RESULTS: AGP did not differ among treatment groups at baseline; overall median (Q1, Q3): 0.608 (.526,.727) g/L, P = 0.92. Treatment with rosiglitazone, rhGH, or the combination significantly reduced AGP concentrations from baseline to week 12, compared to placebo (time by treatment interaction, P = 0.0038). Baseline AGP was not a significant predictor or effect modifier of SI change in response to treatment (P ≥ 0.50). Baseline AGP (g/L) was an independent predictor of VAT change (L) (β = 1.91, SE = 0.89, P = 0.038) in addition to a treatment effect (P < 0.001) and age quartile effect (P < 0.001). No other predictors or interactions were significant, including effect modification of AGP (AGP by treatment interaction P = 0.50). DISCUSSION/SIGNIFICANCE OF IMPACT: It is known that immune and metabolic pathways are highly integrated, and biomarkers of inflammation have predictive abilities for cardiovascular and metabolic disease outcomes. This analysis provides data showing that treatment with rosiglitazone or rhGH in the context of HIV reduces AGP concentrations, indicating efficacy in reducing systemic inflammation. Baseline AGP was an independent risk factor for VAT changes as those with lower AGP at baseline showed a greater reduction in VAT in response to treatment. Biomarkers of inflammation may provide prognostic information for individualized patient outcomes to help guide treatment and follow-up.
To assess the feasibility of non-contrast T2-weighted magnetic resonance imaging as compared to T1-weighted post-contrast magnetic resonance imaging for detecting acoustic neuroma growth.
Adult patients with acoustic neuroma who underwent at least three magnetic resonance imaging scans of the internal auditory canals with and without contrast in the past nine years were identified. T1- and T2-weighted images were reviewed by three neuroradiologists, and tumour size was measured. Accuracy of the measurements on T2-weighted images was defined as a difference of less than or equal to 2 mm from the measurement on T1-weighted images.
A total of 107 magnetic resonance imaging scans of 26 patients were reviewed. Measurements on T2-weighted magnetic resonance imaging scans were 88 per cent accurate. Measurements on T2-weighted images differed from measurements on T1-weighted images by an average of 1.27 mm, or 10.4 per cent of the total size. The specificity of T2-weighted images was 88.2 per cent and the sensitivity was 77.8 per cent.
The T2-weighted sequences are fairly accurate in measuring acoustic neuroma size and identifying growth if one keeps in mind the caveats associated with the tumour characteristics or location.
Mixing matrices quantify how people with similar or different characteristics make contact with each other, creating potential for disease transmission. Little empirical data on mixing patterns among persons who inject drugs (PWID) are available to inform models of blood-borne disease such as HIV and hepatitis C virus. Egocentric drug network data provided by PWID in Baltimore, Maryland between 2005 and 2007 were used to characterise drug equipment-sharing patterns according to age, race and gender. Black PWID and PWID who were single (i.e. no stable sexual partner) self-reported larger equipment-sharing networks than their white and non-single counterparts. We also found evidence of assortative mixing according to age, gender and race, though to a slightly lesser degree in the case of gender. Highly assortative mixing according to race and gender highlights the existence of demographically isolated clusters, for whom generalised treatment interventions may have limited benefits unless targeted directly. These findings provide novel insights into mixing patterns of PWID for which little empirical data are available. The age-specific assortativity we observed is also significant in light of its role as a key driver of transmission for other pathogens such as influenza and tuberculosis.
Research demonstrates the importance of nutrition for early brain development. Few studies have examined the effectiveness of multiple micronutrient powders (MNP) on child development. This study examined the impacts of home fortification with MNP on motor and mental development, executive function and memory of children living in Bihar. This two-arm cluster-randomised effectiveness trial selected seventy health sub-centres to receive either MNP and nutrition counselling (intervention) or nutrition counselling alone (control) for 12 months. Front-line health workers delivered the intervention to all households in study communities with a child aged 6–18 months. Data were collected using cross-sectional surveys at baseline and endline by selecting households from intervention (baseline, n 2184; endline, n 2170) and control (baseline, n 2176; endline, n 2122) communities using a two-stage cluster-randomised sampling strategy. Children in the intervention group had a significantly larger improvement from baseline to endline compared with those in the control group on scores for motor and mental development (Cohen’s d, motor=0·12; 95 % CI 0·03, 0·22; mental=0·15; 95 % CI 0·06, 0·25). Greater impacts of MNP on motor and mental development were observed in children from households with higher stimulation scores at baseline compared with those with lower stimulation (Cohen’s d, motor=0·20 v. 0·09; mental=0·22 v. 0·14; Pinteraction<0·05). No significant treatment differences were seen for executive function or memory. Home fortification with MNP through the existing health infrastructure in Bihar was effective in improving motor and mental development and should be considered in combination with other child development interventions such as stimulation.
Children with a history of maltreatment suffer from altered emotion processing but the neural basis of this phenomenon is unknown. This pioneering functional magnetic resonance imaging (fMRI) study investigated the effects of severe childhood maltreatment on emotion processing while controlling for psychiatric conditions, medication and substance abuse.
Twenty medication-naive, substance abuse-free adolescents with a history of childhood abuse, 20 psychiatric control adolescents matched on psychiatric diagnoses but with no maltreatment and 27 healthy controls underwent a fMRI emotion discrimination task comprising fearful, angry, sad happy and neutral dynamic facial expressions.
Maltreated participants responded faster to fearful expressions and demonstrated hyper-activation compared to healthy controls of classical fear-processing regions of ventromedial prefrontal cortex (vmPFC) and anterior cingulate cortex, which survived at a more lenient threshold relative to psychiatric controls. Functional connectivity analysis, furthermore, demonstrated reduced connectivity between left vmPFC and insula for fear in maltreated participants compared to both healthy and psychiatric controls.
The findings show that people who have experienced childhood maltreatment have enhanced fear perception, both at the behavioural and neurofunctional levels, associated with enhanced fear-related ventromedial fronto-cingulate activation and altered functional connectivity with associated limbic regions. Furthermore, the connectivity adaptations were specific to the maltreatment rather than to the developing psychiatric conditions, whilst the functional changes were only evident at trend level when compared to psychiatric controls, suggesting a continuum. The neurofunctional hypersensitivity of fear-processing networks may be due to childhood over-exposure to fear in people who have been abused.
Childhood abuse is associated with abnormalities in brain structure and function. Few studies have investigated abuse-related brain abnormalities in medication-naïve, drug-free youth that also controlled for psychiatric comorbidities by inclusion of a psychiatric control group, which is crucial to disentangle the effects of abuse from those associated with the psychiatric conditions.
Cortical volume (CV), cortical thickness (CT) and surface area (SA) were measured in 22 age- and gender-matched medication-naïve youth (aged 13–20) exposed to childhood abuse, 19 psychiatric controls matched for psychiatric diagnoses and 27 healthy controls. Both region-of-interest (ROI) and whole-brain analyses were conducted.
For the ROI analysis, the childhood abuse group compared with healthy controls only, had significantly reduced CV in bilateral cerebellum and reduced CT in left insula and right lateral orbitofrontal cortex (OFC). At the whole-brain level, relative to healthy controls, the childhood abuse group showed significantly reduced CV in left lingual, pericalcarine, precuneus and superior parietal gyri, and reduced CT in left pre-/postcentral and paracentral regions, which furthermore correlated with greater abuse severity. They also had increased CV in left inferior and middle temporal gyri relative to healthy controls. Abnormalities in the precuneus, temporal and precentral regions were abuse-specific relative to psychiatric controls, albeit at a more lenient level. Groups did not differ in SA.
Childhood abuse is associated with widespread structural abnormalities in OFC–insular, cerebellar, occipital, parietal and temporal regions, which likely underlie the abnormal affective, motivational and cognitive functions typically observed in this population.
To examine dietary Na and K intake at eating occasions in Australian adults and identify the contribution of major food sources to Na and K at different eating occasions.
Secondary analysis of 24 h recall diet data from the Australian Health Survey (2011–2013).
Nationally representative survey in Australia.
Male and female Australians aged 18–84 years (n 7818).
Dinner contributed the greatest proportion to total daily Na intake (33 %) and K intake (35 %). Na density was highest at lunch (380 mg/MJ) and K density highest at between-meal time eating occasions (401 mg/MJ). Between-meal time eating occasions provided 20 % of daily Na intake and 26 % of daily K intake. The major food group sources of Na were different at meal times (breads and mixed dishes) compared with between-meal times (cakes, muffins, scones, cake-type desserts). The top food group sources of K at meal times were potatoes and unprocessed meat products and dishes.
Foods which contributed to Na and K intake differed according to eating occasion. Major food sources of Na were bread and processed foods. Major food sources of K were potatoes and meat products and dishes. Public health messages that emphasise meal-based advice and diet patterns high in vegetables, fruits and unprocessed foods may also aid reduction in dietary Na intake and increase in dietary K intake.
Predicting recurrent Clostridium difficile infection (rCDI) remains difficult. METHODS. We employed a retrospective cohort design. Granular electronic medical record (EMR) data had been collected from patients hospitalized at 21 Kaiser Permanente Northern California hospitals. The derivation dataset (2007–2013) included data from 9,386 patients who experienced incident CDI (iCDI) and 1,311 who experienced their first CDI recurrences (rCDI). The validation dataset (2014) included data from 1,865 patients who experienced incident CDI and 144 who experienced rCDI. Using multiple techniques, including machine learning, we evaluated more than 150 potential predictors. Our final analyses evaluated 3 models with varying degrees of complexity and 1 previously published model.
Despite having a large multicenter cohort and access to granular EMR data (eg, vital signs, and laboratory test results), none of the models discriminated well (c statistics, 0.591–0.605), had good calibration, or had good explanatory power.
Our ability to predict rCDI remains limited. Given currently available EMR technology, improvements in prediction will require incorporating new variables because currently available data elements lack adequate explanatory power.
To investigate the feasibility of a national audit of epistaxis management led and delivered by a multi-region trainee collaborative using a web-based interface to capture patient data.
Six trainee collaboratives across England nominated one site each and worked together to carry out this pilot. An encrypted data capture tool was adapted and installed within the infrastructure of a university secure server. Site-lead feedback was assessed through questionnaires.
Sixty-three patients with epistaxis were admitted over a two-week period. Site leads reported an average of 5 minutes to complete questionnaires and described the tool as easy to use. Data quality was high, with little missing data. Site-lead feedback showed high satisfaction ratings for the project (mean, 4.83 out of 5).
This pilot showed that trainee collaboratives can work together to deliver an audit using an encrypted data capture tool cost-effectively, whilst maintaining the highest levels of data quality.
Objectives: Verbal episodic memory is a key domain of impairment in people with schizophrenia with close ties to a variety of aspects of functioning and therapeutic treatment response. A randomized, blinded trial of two mnemonic strategies for verbal episodic memory deficits for people with schizophrenia was conducted. Methods: Sixty-one people with schizophrenia were assigned to one of three experimental conditions: training in a mnemonic strategy that included both visualization and narrative structure (Story Method), a condition in which participants were trained to visualize words interacting with one another (Imagery), or a non-trained control condition in which participants received equivalent exposure to training word lists and other verbal memory assessments administered in the other two conditions, but without provision of any compensatory mnemonic strategy. Participants were assessed on improvements in recall of the word list used as part of training, as well as two, standardized verbal memory assessments which included stimuli not used as part of strategy training. Results: The Story Method produced improvements on a trained word list that generalized to a non-trained, prose memory task at a 1-week follow-up. In contrast, provision of a mnemonic strategy of simple visualization of words produced little improvement on word recall of trained words or on measures of generalization relative to the performance of participants in the control condition. Conclusions: These findings support the inclusion of enriched mnemonic strategies consisting of both visualization and narrative structure in sustained and comprehensive programs of CR for enhancement of verbal episodic memory in schizophrenia. (JINS, 2017, 23, 352–357)
Despite significant advances in technological methods for hand hygiene surveillance, a lack of evidence prohibits comparison of systems to one another or against the current gold standard of direct observation.
To validate a hand hygiene monitoring technology (HHMT) designed to capture hand hygiene behaviors aggregated at the hospital-unit level (GOJO Industries, Akron, OH).
Our team followed a rigorous validation approach to assess the sensitivity and positive predictive value (PPV) of an HHMT. A planned path was first used to measure the accuracy of the system when purposefully activated by investigators. Next, behavioral validation was used to quantify accuracy of the system in capturing real-world behaviors.
During the planned path phase, investigators performed 4,872 unique events across 3 distinct hospital buildings varying in size and age since construction. Overall sensitivity across the medical center was 88.7% with a PPV of 99.2%. During the behavioral validation phase, trained direct observers recorded 5,539 unique events across 3 distinct hospital buildings. Overall sensitivity across the medical center was 92.7% and PPV was 84.4%.
Objective measures of sensitivity and PPV indicate the promise of the benefit of this and other HHMTs to capture basic behaviors associated with hand hygiene.
To assess the likelihood of antimicrobial streamlining between 2 antimicrobial stewardship methods.
Retrospective cohort study.
Large academic medical center.
Frequency and time to antimicrobial streamlining were compared during a prior authorization and a prospective audit period. Streamlining was defined as an antimicrobial change to a narrower agent if available or to a broader agent if the isolate was resistant to empiric therapy. Patients included were ≥18 years old with monomicrobial bacteremia with S. aureus, Enterococcus spp., or any aerobic Gram-negative organism.
A total of 665 cases of bacteremia met inclusion criteria. Frequency of streamlining was similar between periods for all cases of bacteremia (audit vs restriction: 60.7% vs 53.2%; P=.12), S. aureus bacteremia (73.2% vs 76.9%; P=.671), and Enterococcus bacteremia (81.6% vs 71.9%; P=.335). Compared to restriction, the audit period was associated with an increased frequency of streamlining for cases of Gram-negative bacteremia (51.4% vs 35.6%; odds ratio [OR], 1.85; 95% confidence interval [CI], 1.06–3.25), those on the medical service (67.9% vs 53.1%; OR, 1.86; 95% CI, 1.09–3.16), and those admitted through the emergency department (71.6% vs 51.4%; OR, 2.32; 95% CI, 1.24–4.34). Characteristics associated with increased streamlining included: absence of β-lactam allergy (P<.001), Gram-negative bacteremia (P<.001), admission through the emergency department (P=.001), and admission to a medical service (P=.011).
Compared with prior authorization, prospective audit increased antimicrobial streamlining for cases of Gram-negative bacteremia, those admitted through the emergency department, and those admitted to a medical but not surgical service.
To examine self-reported practices and policies to reduce infection and transmission of multidrug-resistant organisms (MDRO) in healthcare settings outside the United States.
International members of the Society for Healthcare Epidemiology of America (SHEA) Research Network.
Electronic survey of infection control and prevention practices, capabilities, and barriers outside the United States and Canada. Participants were stratified according to their country’s economic development status as defined by the World Bank as low-income, lower-middle-income, upper-middle-income, and high-income.
A total of 76 respondents (33%) of 229 SHEA members outside the United States and Canada completed the survey questionnaire, representing 30 countries. Forty (53%) were high-, 33 (43%) were middle-, and 1 (1%) was a low-income country. Country data were missing for 2 respondents (3%). Of the 76 respondents, 64 (84%) reported having a formal or informal antibiotic stewardship program at their institution. High-income countries were more likely than middle-income countries to have existing MDRO policies (39/64 [61%] vs 25/64 [39%], P=.003) and to place patients with MDRO in contact precautions (40/72 [56%] vs 31/72 [44%], P=.05). Major barriers to preventing MDRO transmission included constrained resources (infrastructure, supplies, and trained staff) and challenges in changing provider behavior.
In this survey, a substantial proportion of institutions reported encountering barriers to implementing key MDRO prevention strategies. Interventions to address capacity building internationally are urgently needed. Data on the infection prevention practices of low income countries are needed.
Most research on interventions to counter stigma and discrimination has
focused on short-term outcomes and has been conducted in high-income
To synthesise what is known globally about effective interventions to
reduce mental illness-based stigma and discrimination, in relation first
to effectiveness in the medium and long term (minimum 4 weeks), and
second to interventions in low- and middle-income countries (LMICs).
We searched six databases from 1980 to 2013 and conducted a
multi-language Google search for quantitative studies addressing the
research questions. Effect sizes were calculated from eligible studies
where possible, and narrative syntheses conducted. Subgroup analysis
compared interventions with and without social contact.
Eighty studies (n = 422 653) were included in the
review. For studies with medium or long-term follow-up (72, of which 21
had calculable effect sizes) median standardised mean differences were
0.54 for knowledge and −0.26 for stigmatising attitudes. Those containing
social contact (direct or indirect) were not more effective than those
without. The 11 LMIC studies were all from middle-income countries.
Effect sizes were rarely calculable for behavioural outcomes or in LMIC
There is modest evidence for the effectiveness of anti-stigma
interventions beyond 4 weeks follow-up in terms of increasing knowledge
and reducing stigmatising attitudes. Evidence does not support the view
that social contact is the more effective type of intervention for
improving attitudes in the medium to long term. Methodologically strong
research is needed on which to base decisions on investment in
State Pension Age (SPA) is an issue of topical interest in the United Kingdom at the time of writing owing to the Government’s plans to link SPA at future dates to estimates of the projected longevity of the population. This paper considers the background to the current position, how the linkage is proposed to work, other factors that may need to be considered and some changes in the proposed State pension regime that could be alternatives to, or complementary with, a changing SPA.
This article describes a review undertaken in 2012–2013 by Nutrition and Dietetics, Flinders University, to assess the Indigenous health curriculum of the Bachelor of Nutrition and Dietetics (BND) and Masters of Nutrition and Dietetics (MND). An action research framework was used to guide and inform inquiry. This involved four stages, each of which provided information to reach a final decision about how to progress forward. First, relevant information was collected to present to stakeholders. This included identification of acknowledged curriculum frameworks, a review of other accredited nutrition and dietetics courses in Australia, a review of Indigenous health topics at Flinders University, including liaison with the Poche Centre for Indigenous Health and Well-Being (Indigenous health teaching and research unit), and a review of BND and MND current curriculum related to Indigenous health. Second, input was sought from stakeholders. This involved a workshop with practising dietitians and nutritionists from South Australia and the Northern Territory and discussions with Flinders University Nutrition and Dietetics academic staff. Third, a new curriculum was developed. Nine areas were identified for this curriculum, including reflexivity, approach and role, history and health status, worldview, beliefs and values, systems and structures, relationship building and communication, food and food choice, appreciating and understanding diversity, and nutrition issues and health status. Fourth, a final outcome was achieved, which was the decision to introduce a core, semester-long Indigenous health topic for BND students. A secondary outcome was strengthening of Indigenous health teaching across the BND and MND. The process and findings will be useful to other university courses looking to assess and expand their Indigenous health curriculum.
Background: Ciliary mutations cause multi-system disorders, often involving the CNS. We set to evaluate the prevalence of ciliary dysfunction in children with isolated neuroanatomical defects, by measuring nasal nitric oxide (nNO), a screening test for Primary Ciliary Dyskinesia (PCD). Study design: We measured nNO levels of 26 children with congenital midline CNS defects. We evaluated the effect of age, gender, and anomaly (brain, spinal cord, or combined) on measurements. We compared our results to the previously established normal range (153.6-509.9 nL/min), and to the cutoff for PCD (77 nL/min). Results: The range for nNO in our cohort was 56.5-334.7 nL/min, with age, gender, and anomaly not having a significant effect. The overall mean, 217.7 nL/min, was significantly lower than that of normal children, 314.51 nL/min (p<0.01). Four subjects (15.4%) had nNO levels below the lower end of normal, with two (7.7%) having values fitting the cutoff for PCD. Conclusions: We report an association between ciliary dysfunction and isolated midline neuroanatomical defects, not in context of any known syndrome. This suggests that genes causing isolated CNS defects, may be implied in the function of cilia. Longitudinal studies are required to investigate whether children with abnormal measurements suffer from any respiratory sequelae.