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Whether unintentional or by design, built, social, and perceived environments influence the human experience. Behavior is not solely the product of a rational motivated actor, operating independently from his or her environment; rather, it is also a function of edifices, neighborhoods, and public spaces, as well as the inhabitants, community norms, and the social capital they generate. Likewise, addictive behaviors have as much to do with the environmental contexts surrounding individuals as with their unique biological factors, specific brain mechanisms, and psychogenic causes. Any attempt to address addiction at either individual or population levels would benefit from careful consideration of the social and contextual influences on cognitions, opportunities, motivations, and behaviors. Interventions informed by this understanding are more likely to be efficacious than those solely targeted toward individual biology, motivations, or attitudes. In this chapter, we discuss the relationship between physical and social environments (PSE), health, and the behavior of humans. We then focus on the influential role of the PSE on the consumption of alcohol, tobacco, and other substances; food, eating behaviors, and addictions contributing to the current obesity epidemic; and a selection of other behavioral addictions. The chapter closes by discussing methodological considerations and implications for professional practice.
Iron-rich meteorites are significantly underrepresented in collection statistics from Antarctica. This has led to a hypothesis that there is a sparse layer of iron-rich meteorites hidden below the surface of the ice, thereby explaining the apparent shortfall. As standard Antarctic meteorite collecting techniques rely upon a visual surface search approach, the need has thus arisen to develop a system that can detect iron objects under a few tens of centimetres of ice, where the expected number density is of the order one per square kilometre. To help answer this hypothesis, a large-scale pulse induction metal detector array has been constructed for deployment in Antarctica. The metal detector array is 6 m wide, able to travel at 15 km h-1 and can scan 1 km2 in ~11 hours. This paper details the construction of the metal detector system with respect to design criteria, notably the ruggedization of the system for Antarctic deployment. Some preliminary results from UK and Antarctic testing are presented. We show that the system performs as specified and should reach the pre-agreed target of the detection of a 100 g iron meteorite at 300 mm when deployed in Antarctica.
Simulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM).
Simulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators.
Twenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology.
This study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.
Cardiovascular disease is a leading cause of morbidity and mortality in childhood cancer survivors. Cardiologists must be aware of risk factors and long-term follow-up guidelines, which have historically been the purview of oncologists. Little is known about paediatric cardiologists’ knowledge regarding the cardiotoxicity of cancer treatment and how to improve this knowledge.
A total of 58 paediatric cardiologists anonymously completed a 21-question, web-based survey focused on four cardio-oncology themes: cancer treatment-related risk factors (n = 6), patient-related risk factors (n = 6), recommended surveillance (n = 3), and cardiac-specific considerations (n = 6). Following the baseline survey, a multi-disciplinary team of paediatric cardiologists and cancer survivor providers developed an in-person and web-based educational intervention. A post-intervention survey was conducted 5 months later.
The response rate was 41/58 (70.7%) pre-intervention and 30/58 (51.7%) post-intervention. On the baseline survey, the percentage of correct answers was 68.8 ± 10.3%, which improved to 79.2 ± 16.2% after the intervention (p = 0.009). The theme with the most profound knowledge deficit was surveillance; however, it also had the greatest improvement after the intervention (49.6 ± 26.7 versus 66.7 ± 27.7% correct, p = 0.025). Individual questions with the largest per cent improvement pertained to risk of cardiac dysfunction with time since treatment (52.4 versus 93.1%, p = 0.002) and the role of dexrazoxane (48.8 versus 82.8%, p = 0.020).
Specific knowledge deficits about the care of paediatric cancer survivors were identified amongst cardiologists using a web-based survey. Knowledge of surveillance was initially lowest but improved the most after an educational intervention. This highlights the need for cardio-oncology-based educational initiatives among paediatric cardiologists.
Around 60 000 people in England live in mental health supported accommodation. There are three main types: residential care, supported housing and floating outreach. Supported housing and floating outreach aim to support service users in moving on to more independent accommodation within 2 years, but there has been little research investigating their effectiveness.
A 30-month prospective cohort study investigating outcomes for users of mental health supported accommodation.
We used random sampling, accounting for relevant geographical variation factors, to recruit 87 services (22 residential care, 35 supported housing and 30 floating outreach) and 619 service users (residential care 159, supported housing 251, floating outreach 209) across England. We contacted services every 3 months to investigate the proportion of service users who successfully moved on to more independent accommodation. Multilevel modelling was used to estimate how much of the outcome and cost variations were due to service type and quality, after accounting for service-user characteristics.
Overall 243/586 participants successfully moved on (residential care 15/146, supported housing 96/244, floating outreach 132/196). This was most likely for floating outreach service users (versus residential care: odds ratio 7.96, 95% CI 2.92–21.69, P < 0.001; versus supported housing: odds ratio 2.74, 95% CI 1.01–7.41, P < 0.001) and was associated with reduced costs of care and two aspects of service quality: promotion of human rights and recovery-based practice.
Most people do not move on from supported accommodation within the expected time frame. Greater focus on human rights and recovery-based practice may increase service effectiveness.
Patan Hospital, located in Kathmandu Valley, Nepal is a 400-bed hospital that has a long history of responding to natural disasters. Hospital personnel have worked with the Ministry of Health (MOH) and the World Health Organization (WHO) to develop standardized disaster response plans that were implemented in multiple hospital systems after the earthquake of 2015. These plans focused primarily on traumatic events but did not account for epidemics despite the prevalence of infectious diseases in Nepal.
To develop and test a robust epidemic/pandemic response plan at Patan Hospital in Kathmandu that would be generalizable to other hospitals nationwide.
Using the existing disaster plan in conjunction with public health and disaster medicine experts,we developed an epidemic response plan focusing on communication and coordination (between the hospital and MOH, among hospital administration and staff), logistics and supplies including personal protective equipment (PPE), and personnel and hospital incident command (IC) training. After development, we tested the plan using a high-fidelity, real-time simulation across the entire hospital and the hospital IC using actors and in conjunction with the MOH and WHO. We adjusted the plan based on lessons learned from this exercise.
Lessons learned from the high-fidelity simulation included the following: uncovering patient flow issues to avoid contamination/infection; layout issues with the isolation area, specifically accounting for donning/doffing of PPE; more sustained duration of response compared to a natural disaster with implications for staffing and supplies; communication difficulties unique to epidemics; need for national and regional surveillance and inter-facility planning and communication. We adjusted our plan accordingly and created a generalizable plan that can be deployed at an inter-facility and national level.
We learned that this process is feasible in resource-poor hospital systems. Challenges discovered in this process can lead to better national and system-wide preparedness.
OBJECTIVES/SPECIFIC AIMS: Children born with a single ventricle congenital heart defect requires three invasive open-heart surgeries in the first three years of life. The third operation, the Fontan procedure, includes connection of the vena cava (VC) to the pulmonary artery (PA) using a bio-inert conduit to reduce work required by the right ventricle (RV). While this operation greatly extends the lives of HLHS patients, the Fontan circuit eventually fails, and the only solution is a scarcely available donor heart. This failed circuit is explained by the “Fontan paradox” where central venous pressures build up over time, causing increased systemic resistance and congestion. The absence of the sub-pulmonary ventricle leads to abnormal hemodynamics associated with life-threatening complications. We believe that decreasing central venous pressures through the use of a tissue engineered contractile, patient specific conduit will decrease the amount and severity of complications caused by the “Fontan paradox.” We will use amniotic fluid derived induced pluripotent stem cells (AF-iPSCs) differentiated into cardiomyocytes (CMs) to generate flow within a biodegradable conduit. Additionally, AF-iPSC will be differentiated into structural support cells (SSCs), including cardiac fibroblasts and epicardium. Several studies suggest advanced contraction and structure of CMs in specific ratios with SSCs, particularly mouse and human fetal fibroblasts. In combination, these cells have shown advanced tissue organization and function through mechanically and electrically aligned junctions. This allows them to have a magnitude higher contractile force than CMs alone, making them ideal for increasing pressure within a tissue engineered construct. This poster focuses on the differentiation and selection of SSCs. METHODS/STUDY POPULATION: AF-iPSCs differentiation began at roughly 80% confluency. Mesoderm formation occurred via WNT pathway modulation by supplementing RPMI+insulin media with 0.5 ng/mL BMP4 at day 0, followed by 3 ng/mL BMP4, 2 ng/mL Activin A, and 5 ng/mL BFGF for four days. Then, RPMI+insulin media was supplemented with 10 ng/mL of BMP4 until day fifteen for epicardial formation. Cells were lifted to induce epithelial-to-mesenchymal transition (EMT) and RPMI-insulin media was supplemented with 10 ng/mL BFGF for cardiac fibroblasts. They were then harvested and characterized using immunofluorescence. Planned experiments include RT-qPCR for further characterization of cardiac fibroblasts. Additionally, a fibroblast isolation plating technique will be utilized to obtain cardiac fibroblast from AF-iPSC CMs and AF-iPSC epicardium. Commercially obtained human cardiac fibroblasts will be utilized as a control for all studies. RESULTS/ANTICIPATED RESULTS: Immunofluorescence (IF) revealed positive expression of vimentin and α-SMA indicating a fibroblast and vascular smooth muscle phenotype after supplementation with 10 ng/mL of BMP4 after EMT induction. It is expected that IF of epicardial formation at day 15 will show positive expression of WT1, a well-known epicardial marker. We also suspect RT-qPCR will reveal high expression of cardiac fibroblast specific markers COL1A1, PDGFA, TCF21, and THSB1. We expect to yield a higher number of cardiac fibroblast from the small molecule AF-iPSC differentiation compared to a timed plating technique of AF-iPSC CMs and AF-iPSC epicardium (separately plated). Results will be quantified and compared using the aforementioned techniques. DISCUSSION/SIGNIFICANCE OF IMPACT: Discussion/significance of impact: Although fibroblasts make up a large portion of cells in the heart and greatly enhance CM function, they are poorly characterized in the literature and not easily obtained. This study will provide an efficiency comparison on the best method for acquiring cardiac fibroblast for cardiac tissue engineering applications as we move forward with translational cardiac pediatric research.
Whether monozygotic (MZ) and dizygotic (DZ) twins differ from each other in a variety of phenotypes is important for genetic twin modeling and for inferences made from twin studies in general. We analyzed whether there were differences in individual, maternal and paternal education between MZ and DZ twins in a large pooled dataset. Information was gathered on individual education for 218,362 adult twins from 27 twin cohorts (53% females; 39% MZ twins), and on maternal and paternal education for 147,315 and 143,056 twins respectively, from 28 twin cohorts (52% females; 38% MZ twins). Together, we had information on individual or parental education from 42 twin cohorts representing 19 countries. The original education classifications were transformed to education years and analyzed using linear regression models. Overall, MZ males had 0.26 (95% CI [0.21, 0.31]) years and MZ females 0.17 (95% CI [0.12, 0.21]) years longer education than DZ twins. The zygosity difference became smaller in more recent birth cohorts for both males and females. Parental education was somewhat longer for fathers of DZ twins in cohorts born in 1990–1999 (0.16 years, 95% CI [0.08, 0.25]) and 2000 or later (0.11 years, 95% CI [0.00, 0.22]), compared with fathers of MZ twins. The results show that the years of both individual and parental education are largely similar in MZ and DZ twins. We suggest that the socio-economic differences between MZ and DZ twins are so small that inferences based upon genetic modeling of twin data are not affected.
In situ and operando measurement techniques combined with nanoscale resolution have proven invaluable in multiple fields of study. We argue that evaluating device performance as well as material behavior by correlative X-ray microscopy with <100 nm resolution can radically change the approach for optimizing absorbers, interfaces and full devices in solar cell research. In this article, we thoroughly discuss the measurement technique of X-ray beam induced current and point out fundamental differences between measurements of wafer-based silicon and thin-film solar cells. Based on reports of the last years, we showcase the potential that X-ray microscopy measurements have in combination with in situ and operando approaches throughout the solar cell lifecycle: from the growth of individual layers to the performance under operating conditions and degradation mechanisms. Enabled by new developments in synchrotron beamlines, the combination of high spatial resolution with high brilliance and a safe working distance allows for the insertion of measurement equipment that can pave the way for a new class of experiments. Applied to photovoltaics research, we highlight today’s opportunities and challenges in the field of nanoscale X-ray microscopy, and give an outlook on future developments.
This study aimed to demonstrate proof of concept and acceptability of a brief acceptance and commitment therapy (ACT)-based guided self-help intervention for improving quality of life (QoL) and mood for people with muscle disorders (MD). A case-series with an AB design was used to assess changes in primary (QoL) and secondary (depression and anxiety) outcome variables across the period of study. Change in the psychological process targeted by ACT – psychological flexibility – was also investigated, to allow insight into possible treatment mechanisms. Post-intervention, participants also completed a brief free-text evaluation. Relative to pre-intervention scores, four (of seven) participants showed varying degrees of improvement in all primary and secondary outcome variables and were thus considered responders. However, consistent concomitant improvements in psychological flexibility were not apparent. Participants reported a mostly positive experience of the intervention; all appeared to complete the intervention, and no adverse events were reported. Nonetheless, there was evidence that those with compromised concentration or who report good initial QoL and low levels of distress may derive less benefit. Although several methodological weaknesses limit the strength of our conclusions, this ACT-based guided self-help intervention shows encouraging utility for improving QoL and mood in MD.
We support Pepper and Nettle's (P&N's) hypothesised adaptive responses to deprivation. However, we argue that adaptive responses to stress shift with age. Specifically, present-oriented behaviours are adaptive for young people (e.g., in terms of mating and reproduction) but costly for older people in deprived communities who would benefit from investing in grandchildren. Epigenetic mechanisms may be responsible for age-related tactical shifts.
The emergency department (ED) left-without-being-seen (LWBS) rate is a performance indicator, although there is limited knowledge about why people leave, or whether they seek alternate care. We studied characteristics of ED LWBS patients to determine factors associated with LWBS.
We collected demographic data on LWBS patients at two urban hospitals. Sequential LWBS patients were contacted and surveyed using a standardized telephone survey. A matched group of patients who did not leave were also surveyed. Data were analysed using the Fisher exact test, chi-square test, and student t-test.
The LWBS group (n=1508) and control group (n=1504) were matched for sex, triage category, recorded wait times, employment and education, and having a family physician. LWBS patients were younger, more likely to present in the evening or at night, and lived closer to the hospital. A long wait time was the most cited reason for leaving (79%); concern about medical condition was the most common reason for staying (96%). Top responses for improved likelihood of waiting were shorter wait times (LWBS, 66%; control, 31%) and more information on wait times (41%; 23%). A majority in both groups felt that their condition was a true emergency (63%; 72%). LWBS patients were more likely to seek further health care (63% v. 28%; p<0.001) and sooner (median time 1 day v. 2-4 days; p=0.002). Among patients who felt that their condition was not a true emergency, the top reason for ED attendance was the inability to see their family doctor (62% in both groups).
LWBS patients had similar opinions, experiences, and expectations as control patients. The main reason for LWBS was waiting longer than expected. LWBS patients were more likely to seek further health care, and did so sooner. Patients wait because of concern about their health problem. Shorter wait times and improved communication may reduce the LWBS rate.
Assessing changes in adolescents’ BMI over brief periods could contribute to detection of acute changes in weight status and prevention of overweight. The objective of this study was to analyse the BMI trajectory and the excessive weight gain of Brazilian adolescents over 3 years and the association with demographic and socio-economic factors. Data regarding the BMI of 1026 students aged between 13 and 19 years were analysed over 3 consecutive years (2010, 2011 and 2012) from the Adolescent Nutritional Assessment Longitudinal Study. Linear mixed effects models were used to assess the BMI trajectory according to the type of school attended (public or private), skin colour, socio-economic status and level of maternal schooling by sex. Associations between excessive weight gain and socio-economic variables were identified by calculation of OR. Boys attending private schools (β coefficient: 0·008; P=0·01), those with white skin (β coefficient: 0·007; P=0·04) and those whose mothers had >8 years of schooling (β coefficient: 0·009; P=0·02) experienced greater BMI increase than boys and girls in other groups. Boys in private schools also presented higher excessive weight gain compared with boys attending public schools (P=0·03). Boys attending private schools experienced greater BMI increase and excessive weight gain, indicating the need to develop specific policies for the prevention and reduction of overweight in this population.
The focus of the review paper is to discuss how biotechnological innovations are opening new frontiers to mitigate nutrition in key agricultural crops with potential for large-scale health impact to people in Africa. The general objective of the Africa Biofortified Sorghum (ABS) project is to develop and deploy sorghum with enhanced pro-vitamin A to farmers and end-users in Africa to alleviate vitamin A-related micronutrient deficiency diseases. To achieve this objective the project technology development team has developed several promising high pro-vitamin A sorghum events. ABS 203 events are so far the most advanced and well-characterised lead events with about 12 μg β-carotene/g tissue which would supply about 40–50 % of the daily recommended vitamin A at harvest. Through gene expression optimisation other events with higher amounts of pro-vitamin A, including ABS 214, ABS 235, ABS 239 with 25, 30–40, 40–50 μg β-carotene/g tissue, respectively, have been developed. ABS 239 would provide twice recommended pro-vitamin A at harvest, 50–90 % after 3 months storage and 13–45 % after 6 months storage for children. Preliminary results of introgression of ABS pro-vitamin A traits into local sorghum varieties in target countries Nigeria and Kenya show stable introgression of ABS vitamin A into local farmer-preferred sorghums varieties. ABS gene Intellectual Property Rights and Freedom to Operate have been donated for use royalty free for Africa. Prior to the focus on the current target countries, the project was implemented by fourteen institutions in Africa and the USA. For the next 5 years, the project will complete ABS product development, complete regulatory science data package and apply for product deregulation in target African countries.