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Clinical trial participation among US Hispanics remains low, despite a significant effort by research institutions nationwide. ResearchMatch, a national online platform, has matched 113,372 individuals interested in participating in research with studies conducted by 8778 researchers. To increase accessibility to Spanish speakers, we translated the ResearchMatch platform into Spanish by implementing tenets of health literacy and respecting linguistic and cultural diversity across the US Hispanic population. We describe this multiphase process, preliminary results, and lessons learned.
Translation of the ResearchMatch site consisted of several activities including: (1) improving the English language site’s reading level, removing jargon, and using plain language; (2) obtaining a professional Spanish translation of the site and incorporating iterative revisions by a panel of bilingual community members from diverse Hispanic backgrounds; (3) technical development and launch; and (4) initial promotion.
The Spanish language version was launched in August 2018, after 11 months of development. Community input improved the initial translation, and early registration and use by researchers demonstrate the utility of Spanish ResearchMatch in engaging Hispanics. Over 12,500 volunteers in ResearchMatch self-identify as Hispanic (8.5%). From August 2018 to March 2020, 162 volunteers registered through the Spanish language version of ResearchMatch, and over 500 new and existing volunteers have registered a preference to receive messages about studies in Spanish.
By applying the principles of health literacy and cultural competence, we developed a Spanish language translation of ResearchMatch. Our multiphase approach to translation included key principles of community engagement that should prove informative to other multilingual web-based platforms.
Reduced inflammatory signaling (IL-1RI-/-) alters metabolic responses to dietary challenges (1). Inflammasome deficiency (e.g. IL-18-/-, Asc-/-) can modify gut microbiota concomitant with hepatosteatosis; an effect that was transferable to wild-type (WT) mice by co-housing (2). Taken together, this evidence suggests that links between diet, microbiota and IL-1RI-signaling can influence metabolic health. Our aim was to determine whether IL-1RI-mediated signaling interacted with the gut microbiome to impact metabolic tissue functionality in a diet-specific fashion. Male WT (C57BL/J6) and IL-1RI-/- mice were fed either high-fat diet (HFD; 45% kcal) or low-fat diet (LFD; 10% kcal) for 24 weeks and were housed i) separately by genotype or ii) with genotypes co-housed together (i.e. isolated vs shared microbial environment; n = 8–10 mice per group). Glucose tolerance and insulin secretion response (1.5 g/kg i.p.), gut microbiota composition and caecal short-chain fatty acids (SCFA) were assessed. Liver and adipose tissue were harvested and examined for triacylglycerol (TAG) formation, cholesterol and metabolic markers (Fasn, Cpt1α, Pparg, Scd1, Dgat1/2), using histology, gas-chromatography and RT-PCR, respectively. Statistical analysis included 1-way or 2-way ANOVA, where appropriate, with Bonferroni post-hoc correction. Co-housing significantly affected gut microbiota composition, illustrated by clustering in PCoA (unweighted UniFrac distance) of co-housed mice but not their single-housed counterparts, on both HFD and LFD. The taxa driving these differences were primarily from Lachnospiraceae and Ruminococcaceae families. Single-housed WT had lower hepatic weight, TAG, cholesterol levels and Fasn despite HFD, an effect lost in their co-housed counterparts, who aligned more to IL-1RI-/- hepatic lipid status. Hepatic Cpt1α was lowest in co-housed WT. Adipose from IL-1RI-/- groups on HFD displayed increased adipocyte size and reduced adipocyte number compared to WT groups, but greater lipogenic potential (Pparg, Scd1, Dgat2) alongside a blunted IL-6 response to pro-inflammatory stimuli (~32%, P = 0.025). Whilst caecal SCFA concentrations were not different between groups, single-housed IL-1RI-/- adipocytes showed greatest sensitivity to SCFA-induced lipogenesis. Interestingly, differences in tissue functionality and gut microbiome occurred despite unaltered glucose tolerance; although there was a trend for phenotypic transfer of body weight via co-housing. For all endpoints examined, similar genotype/co-housing effects were observed for both HFD and LFD with the greatest impacts seen in HFD-fed mice. In conclusion, while the gut microbiome may be an important consideration in dietary interventions, these results question the magnitude of its impact in relation to the IL-1RI-dependent immunometabolism-glucose homeostasis axis.
Accurate localisation of target position is crucial when using techniques with sharp dose fall off such as volumetric modulated arc therapy (VMAT). Gold seed fiducial markers have been used for target localisation in image-guided radiation therapy for various tumors including intact prostate cancers. However, their role for target localisation in post-prostatectomy radiotherapy is unclear. This study was undertaken to determine the feasibility and effectiveness of gold seed fiducial markers in patients undergoing prostate bed VMAT.
Materials and methods:
The institutional radiation oncology database was used to analyse the treatment data of 18 post-prostatectomy patients with implanted gold seed fiducial markers. The shifts of the fiducial markers were reviewed, tabulated and statistically analysed.
Three hundred and eighty-six orthogonal pair images for 18 patients were reviewed. Specifically, the average gold seed fiducial shifts were 0·34 cm in the superior–inferior (S/I) axis (0·31 SD), 0·31 cm (0·29 SD) in the anterior–posterior (A/P) axis and 0·28 cm (0·25 SD) in the lateral axis (R/L). As a result, the 95% probability of fiducial marker displacement was 0·96 cm in the S/I, 0·89 cm in the A/P and 0·78 cm in the R/L axes. The most frequent shifts occurred in the inferior, left and posterior directions. The percentage of shifts more than 0·5 cm were 19·74, 21·56 and 12·47% for the S/I, A/P and R/L axes, respectively.
In the absence of fiducial markers, non-uniform planning target volume (PTV) margins of 1 cm for S/I, 9 mm for A/P and 8 mm for the lateral direction are necessary for target localisation in post-prostatectomy radiotherapy. By improving prostate bed localisation, gold seed fiducial markers can decrease PTV margins, reduce normal tissue radiation exposure and allow for dose-escalated and/or hypofractionated radiotherapy to be considered in appropriate clinical scenarios.
Individuals experiencing different medical conditions, as well as healthy volunteers, may often be interested in trial participation, and researchers similarly need to find participants to advance medical knowledge. The ResearchMatch (RM) Trials Today clinical trial searching tool leverages clinicaltrials.gov data to enable potential participants to look for trial opportunities relevant to their situation. To facilitate expanded use of this tool, we undertook a national digital public awareness campaign to increase awareness of Trials Today among members of the general public.
The awareness campaign promoted Trials Today using Facebook and digital banner messages in 2017, encompassing nine cities across the USA. The digital strategy was complemented by print media in several outlets. We employed descriptive statistics to summarize campaign metrics and site usage data during the campaign.
The campaign was successful in increasing visits to Trials Today, with 142,303 sessions logged during its run, as compared to pre-campaign data indicating 104,688 total sessions during the entire 2-year period since the site’s inception. The city-specific click-through rate for all digital impressions, combining Facebook and banner messaging, ranged from 0.50% to 1.09%, resulting in a cost-per-click range of $0.69–$1.15. In addition, visitors conducted 29,697 searches and viewed individual trial records 173,512 times.
The public awareness campaign was successful in increasing use of the RM Trials Today clinical trial searching tool. Our findings support the value of digital media messaging as a cost-effective vehicle for promoting clinical trial awareness, especially for chronic ailments.
Inadequate protein quality may be a risk factor for poor growth. To examine the effect of a macronutrient–micronutrient supplement KOKO Plus (KP), provided to infants from 6 to 18 months of age, on linear growth, a single-blind cluster-randomised study was implemented in Ghana. A total of thirty-eight communities were randomly allocated to receive KP (fourteen communities, n 322), a micronutrient powder (MN, thirteen communities, n 329) and nutrition education (NE, eleven communities, n 319). A comparison group was followed cross-sectionally (n 303). Supplement delivery and morbidity were measured weekly and anthropometry monthly. NE education was provided monthly. Baseline, midline and endline measurements at 6, 12 and 18 months included venous blood draws, diet, anthropometry, morbidity, food security and socio-economics. Length-for-age Z-score (LAZ) was the primary outcome. Analyses were intent-to-treat using mixed-effects regressions adjusted for clustering, sex, age and baseline. No differences existed in mean LAZ scores at endline (−1·219 (sd 0·06) KP, −1·211 (sd 0·03) MN, −1·266 (sd 0·03) NE). Acute infection prevalence was lower in the KP than NE group (P = 0·043). Mean serum Hb was higher in KP infants free from acute infection (114·02 (sd 1·87) g/l) than MN (107·8 (sd 2·5) g/l; P = 0·047) and NE (108·8 (sd 0·99) g/l; P = 0·051). Compliance was 84·9 % (KP) and 87·2 % (MN) but delivery 60 %. Adjusting for delivery and compliance, LAZ score at endline was significantly higher in the KP v. MN group (+0·2 LAZ; P = 0·026). A macro- and micronutrient-fortified supplement KP reduced acute infection, improved Hb and demonstrated a dose–response effect on LAZ adjusting consumption for delivery.
Professor Paul Kennedy sadly passed away in 2016 during the production of this book. Paul was Professor of Clinical Psychology at the University of Oxford and Trust Head of Clinical Psychology at the National Spinal Injuries Centre, Stoke Mandeville Hospital, a British Clinical Psychologist of international renown, distinguished academic and an inspiring leader in his field.
Delays in triage processes in the emergency department (ED) can compromise patient safety. The aim of this study was to provide proof-of-concept that a self-check-in kiosk could decrease the time needed to identify ambulatory patients arriving in the ED. We compared the use of a novel automated self-check-in kiosk to identify patients on ED arrival to routine nurse-initiated patient identification.
We performed a prospective trail with random weekly allocation to intervention or control processes during a 10-week study period. During intervention weeks, patients used a self-check-in kiosk to self-identify on arrival. This electronically alerted triage nurses to patient arrival times and primary complaint before triage. During control weeks, kiosks were unavailable and patients were identified using routine nurse-initiated triage. The primary outcome was time-to-first-identification, defined as the interval between ED arrival and identification in the hospital system.
Median (interquartile range) time-to-first-identification was 1.4 minutes (1.0–2.08) for intervention patients and 9 minutes (5–18) for control patients. Regression analysis revealed that the adjusted time-to-first-identification was 13.6 minutes (95% confidence interval 12.8–14.5) faster for the intervention group.
A self-check-in kiosk significantly reduced the time-to-first-identification for ambulatory patients arriving in the ED.
OBJECTIVES/SPECIFIC AIMS: Clostridium difficile infection (CDI) is the most common cause of antibiotic-associated diarrhea and an increasingly common infection in children in both hospital and community settings. Between 20% and 30% of pediatric patients will have a recurrence of symptoms in the days to weeks following an initial infection. Multiple recurrences have been successfully treated with fecal microbiota transplantation (FMT), though the body of evidence in pediatric patients is limited primarily to case reports and case series. The goal of our study was to better understand practices, success, and safety of FMT in children as well as identify risk factors associated with a failed FMT in our pediatric patients. METHODS/STUDY POPULATION: This multicenter retrospective analysis included 373 patients who underwent FMT for CDI between January 1, 2006 and January 1, 2017 from 18 pediatric centers. Demographics, baseline characteristics, FMT practices, C. difficile outcomes, and post-FMT complications were collected through chart abstraction. Successful FMT was defined as no recurrence of CDI within 60 days after FMT. Of the 373 patients in the cohort, 342 had known outcome data at two months post-FMT and were included in the primary analysis evaluating risk factors for recurrence post-FMT. An additional six patients who underwent FMT for refractory CDI were excluded from the primary analysis. Unadjusted analysis was performed using Wilcoxon rank-sum test, Pearson χ2 test, or Fisher exact test where appropriate. Stepwise logistic regression was utilized to determine independent predictors of success. RESULTS/ANTICIPATED RESULTS: The median age of included patients was 10 years (IQR; 3.0, 15.0) and 50% of patients were female. The majority of the cohort was White (89.0%). Comorbidities included 120 patients with inflammatory bowel disease (IBD) and 14 patients who had undergone a solid organ or stem cell transplantation. Of the 336 patients with known outcomes at two months, 272 (81%) had a successful outcome. In the 64 (19%) patients that did have a recurrence, 35 underwent repeat FMT which was successful in 20 of the 35 (57%). The overall success rate of FMT in preventing further episodes of CDI in the cohort with known outcome data was 87%. Unadjusted predictors of a primary FMT response are summarized. Based on stepwise logistic regression modeling, the use of fresh stool, FMT delivery via colonoscopy, the lack of a feeding tube, and a lower number of CDI episodes before undergoing FMT were independently associated with a successful outcome. There were 20 adverse events in the cohort assessed to be related to FMT, 6 of which were felt to be severe. There were no deaths assessed to be related to FMT in the cohort. DISCUSSION/SIGNIFICANCE OF IMPACT: The overall success of FMT in pediatric patients with recurrent or severe CDI is 81% after a single FMT. Children without a feeding tube, who receive an early FMT, FMT with fresh stool, or FMT via colonoscopy are less likely to have a recurrence of CDI in the 2 months following FMT. This is the first large study of FMT for CDI in a pediatric cohort. These findings, if confirmed by additional prospective studies, will support alterations in the practice of FMT in children.
This paper describes the process of setting up and the early results from a new liaison psychiatry service in primary care for people identified as frequent general practice attenders with long-term conditions or medically unexplained symptoms. Using a rapid evidence synthesis, we identified existing service models, mechanisms to identify and refer patients, and outcomes for the service. Considering this evidence, with local contingencies we defined options and resources. We agreed a model to set up a service in three diverse general practices. An evaluation explored the feasibility of the service and of collecting data for clinical, service and economic outcomes.
High levels of patient and staff satisfaction, and reductions in the utilisation of primary and secondary healthcare, with associated cost savings are reported.
A multidisciplinary liaison psychiatry service integrated in primary care is feasible and may be evaluated using routinely collected data.
We evaluated the use of nesiritide in children with critical CHD, pulmonary congestion, and inadequate urine output despite undergoing conventional diuretic therapy.
We conducted a retrospective analysis of 11 patients with critical CHD, comprising 18 infusions, each of which occurred during separate hospitalisations. Haemodynamic parameters were assessed, and the stage of acute kidney injury was determined before and throughout the duration of therapy using a standardised definition of acute kidney injury – The Kidney Disease: Improving Global Outcomes criteria.
Children with critical CHD, pulmonary congestion, and inadequate urinary output despite undergoing diuretic therapy were included.
Measurements and main results
The use of nesiritide was associated with a significant decrease in the maximum and minimum heart rate values and with a trend towards a significant decrease in maximum systolic blood pressure and maximum and minimum central venous pressures. Urine output increased but was not significant. Serum creatinine levels decreased significantly during the course of therapy (−0.26 mg/dl [−0.50, 0.0], p=0.02), and the number of patients who experienced a decrease in the stage of acute kidney injury of 2 or more – where a change in the stage of acute kidney disease of 2 or more was possible, that is, baseline stage >1 – was highly significant (five of 12 patients, 42%, p<0.001).
Nesiritide had a favourable impact on haemodynamics, and its use was not associated with deterioration of renal function in patients with critical CHD.
ABSTRACT.The 19thcentury was dominated by naval power and seaborne trade, which allowed Britain to reproduce afloat something like the political and economic dominance of the Roman Empire. The Industrial Revolution reinforced British power for a short time, but quickly generated rival naval powers, while the strategic dangers of dependence on overseas markets and raw materials became clearer by the end of the century. An international naval arms race ensued in which Britain was challenged first by France and Russia, then the United States and Germany, but before and during the First World War Britain outspent all of them except the U.S.A., which was glad to get out of the race in 1922 with a nominal equality. The Washington Treaties “froze” the battlefleets of the major powers, and diverted international competition towards the new technology of aircraft. Aircraft in turn, and submarines, were to change the nature of naval war, but the Second World War only confirmed the dominant role of navies in a world war. Post-war economic growth and the container revolution helped to shift the centre of gravity of world trade to the Pacific, and the centre of effort of the U.S. Navy from the Atlantic to the Pacific, but the sea and sea power remain today at the heart of international affairs.
RÉSUMÉ.Le XIXe siècle fut dominé par la puissance navale et le commerce maritime, permettant à la Grande-Bretagne de reproduire sur l'eau une domination économique et politique proche de celle de l'Empire romain. La Révolution industrielle renforça l'autorité britannique pendant une courte période mais suscita rapidement la montée de puissances maritimes rivales. En outre, les dangers stratégiques d'une dépendance aux marchés et matières premières extérieurs devinrent plus clairs à la fin du siècle. Une course à l'armement naval internationale s'ensuivit, pour laquelle la Grande-Bretagne dut tout d'abord faire face à la France et la Russie, puis aux États-Unis et à l'Allemagne. Avant et pendant la première guerre mondiale, elle les surpassa tous, excepté les États-Unis qui se réjouit de sortir de la course en 1922 par une égalité symbolique. Le traité de Washington « gela » les flottes de combat des principales puissances et dispersa la compétition internationale vers la nouvelle technologie aérienne.
Sequential nephron blockade using intravenous chlorothiazide is often used to enhance urine output in patients with inadequate response to loop diuretics. A few data exist to support this practice in critically ill infants.
We included 100 consecutive patients <1 year of age who were administered intravenous chlorothiazide while receiving furosemide therapy in the cardiac ICU in our study. The primary end point was change in urine output 24 hours after chlorothiazide administration, and patients were considered to be responders if an increase in urine output of 0.5 ml/kg/hour was documented. Data on demographic, clinical, fluid intake/output, and furosemide and chlorothiazide dosing were collected. Multivariable regression analyses were performed to determine variables significant for increase in urine output after chlorothiazide administration.
The study population was 48% male, with a mean weight of 4.9±1.8 kg, and 69% had undergone previous cardiovascular surgery. Intravenous chlorothiazide was initiated at 89 days (interquartile range 20–127 days) of life at a dose of 4.6±2.7 mg/kg/day (maximum 12 mg/kg/day). Baseline estimated creatinine clearance was 83±42 ml/minute/1.73 m2. Furosemide dose before chlorothiazide administration was 2.8±1.4 mg/kg/day and 3.3±1.5 mg/kg/day after administration. A total of 43% of patients were categorised as responders, and increase in furosemide dose was the only variable significant for increase in urine output on multivariable analysis (p<0.05). No graphical trends were noted for change in urine output and dose of chlorothiazide.
Sequential nephron blockade with intravenous chlorothiazide was not consistently associated with improved urine output in critically ill infants.
While many great and extended conflicts involving the use of the sea have been fought over the past two thousand years, the three most notable in modern times were undoubtedly those struggles for global mastery in the years 1793–1815, 1914–18 and 1939–45. Each of these conflicts has produced a plethora of detailed works upon aspects of the war in question, but the profession has avoided making a comparative study of them to draw broader conclusions about the influence of sea power in the modern world. This chapter makes an attempt to do that, and with a particular interest in examining why the exercise of naval force during the second of the three conflicts is generally regarded as having had much less effectiveness than in the other two. Examining why naval power in 1914–18 had much less ‘influence’ than its pre-war advocates hoped might then help us to a better understanding of the limitations of naval force as well as of its positive capabilities. Above all, the essay is interested in the changing contexts in which sea power had to operate over these one hundred and fifty years of what one scholar nicely termed ‘the influence of History upon Sea Power’.
This is a lengthy argument, and so the structure of the essay below has been divided, rather obviously, into wartime and peacetime sections. Since the great naval struggle for mastery between 1793 and 1815 is generally regarded as the apotheosis of sea power in action, no detailed account is offered below of the many great battles that took place within those years, or of where British diplomacy and naval influence successfully marched hand in hand, as in the Baltic, or of the campaigns in the Eastern Seas. What seemed more important was to produce a reasonably brief structural analysis of why it was that sea power played such a prominent role in a struggle for the mastery of Europe that in the final analysis obviously had to be settled by military victory over Napoleon on land.