Hemoglobin A1c testing is associated with improved pancreas utilization for transplant.

CONTEXT: Aging, higher prevalence of diabetes, worsening obesity, and hyperglycemia among potential donors increase the likelihood that pancreata will be declined by transplant centers. Hemoglobin A1c testing, also known as glycated hemoglobin testing, identifies a donor's average blood glucose concentration for the preceding 2 to 3 months and is the standard test for identifying prolonged periods of hyperglycemia. OBJECTIVE: To compare pancreas utilization rates before and after implementation of hemoglobin A1c testing. DESIGN: A retrospective study of data from the New York Organ Donor Network was conducted. Potential donors were defined as standard criteria donors who had no history of diabetes and were not seropositive for hepatitis B or C. Criteria for "ideal" potential pancreas donors were based on age, body mass index, lipase level, and terminal creatinine level. Potential donors who did not meet the criteria for ideal donors were considered "expanded" potential pancreas donors. Pancreas utilization rate was defined as the number of pancreata transplanted divided by the number of potential pancreas donors. RESULTS: Of 779 standard criteria donors, 691 (89%) were potential pancreas donors: 251 ideal (36%) and 440 expanded (64%) donors. In 2005 and 2006, before hemoglobin A1c testing, pancreas utilization rates were 21% and 18%, respectively. In 2008, 2009, and 2010, after hemoglobin A1c testing was incorporated, utilization rates were 27%, 28%, and 32%, respectively. Utilization of ideal donors increased from 33% to 51% (P= .003), and utilization of expanded donors increased from 11% to 17% (P= .05). Pancreas utilization increased 51.0%, and pancreas discards decreased 50.8% with the implementation of hemoglobin A1c testing. CONCLUSION: Hemoglobin A1c testing may increase utilization of ideal and expanded criteria pancreata.

Technology and social media use by adult patients with intellectual and/or developmental disabilities.

BACKGROUND: Technology and social media offer individuals with intellectual and/or developmental disabilities (I/DD) unique and innovative ways to facilitate active participation in their own healthcare process. What remains unclear is the extent to which devices are currently used by this growing patient population. OBJECTIVE: To explore the prevalence of technology and social media use, as well as the possible barriers, among adult patients with I/DD. METHODS: A cross-sectional study utilizing an anonymous, accessible survey was used to obtain data from all adult patients (18 + years of age) with I/DD presenting for primary care services at a healthcare facility in New York between September and December of 2016. RESULTS: A total of 370 individuals completed the survey (529 approached, 69.9% response rate). Less than half (44.6%) of respondents used devices such as a tablet, smartphone or desktop; most (86.8%) did not use social media. Only 21.6% of respondents indicated that they use some type of assistive technology. While some respondents (46.0%) were identified by their caregivers as having a disability that would prevent them from learning/using technology, other respondents reported having no challenges (18.0%), needing training and/or ongoing support (7.4%), or being uncertain as to whether they would experience any challenges (15.5%). CONCLUSIONS: Many adult patients with I/DD do not use technology and social media that could promote self-determination and participation in their healthcare. Continued efforts must be made to promote technology use among adults with I/DD and to ensure that appropriate training is available for both the individual and his/her caregivers to achieve adoption and utilization.

Using Personal Digital Assistants to improve self-care in oral health.

We conducted a pilot project to evaluate the potential of Personal Digital Assistant (PDA) technologies to improve the oral health of people with mild to moderate intellectual disabilities, chronic health problems and a long-standing history of poor oral health self-care. Oral health video and audio materials were prepared and transferred to PDAs. Patients were trained in the use of the PDAs at a regular dental appointment and the utilization of the PDA and any change in oral health status was tracked over the next six months. More than half of the 36 patients reported problems in keeping the PDAs functioning properly (mainly problems of keeping the batteries charged) for the duration of the project and 11 patients dropped out of the study. Ten of the remainder (40%) achieved improvement in at least three areas of oral health. The pilot project potentially brings a range of health promotion activities within the reach of people with limited health literacy which may produce better self-management of chronic health conditions.

Evaluation of capnography using a genetic algorithm to predict PaCO2.

INTRODUCTION: Noninvasive estimates of Paco(2) are usually done by measuring exhaled carbon dioxide at end-expiration (Petco(2)). While commonly used in studies involving healthy patients, it is less useful in sicker patients. Conditions that affect the terminal dead space and hence the accuracy of Petco(2) as a surrogate for Paco(2) may also affect other components of the capnogram. A genetic algorithm is a computer technique for discovering relationships between variables. The purpose of this study was to use a genetic algorithm to improve the precision of Paco(2) prediction in comparison to Petco(2). METHODS: Inspiratory and expiratory volumes were measured and analyzed by the computerized capnogram. Data were recorded for 2 min. Within 5 min of recording the capnograms, arterial blood gases were obtained. After excluding artifact and incomplete capnograms, five of the remaining breaths from each patient were selected. A genetic algorithm, constructed in postfix notation, consisted of 1,000 chromosomes with genes randomly selected from the 11 capnographic data fields and mathematical operators. The algorithm was constructed on 400 breaths from 83 randomly selected patients (construction group) and tested on 160 breaths from the remaining 32 patients (test group). RESULTS: For the construction group, the bias and precision between Petco(2) and Paco(2) were 4.3 +/- 4.9 mm Hg (mean +/- SD). For the 160 breaths in the test group, Petco(2) predicted Paco(2) with bias and precision of 2.9 +/- 4.2 mm Hg. The best chromosome found by the genetic algorithm was (10 x 5 + 5 x 5 x 5)/(10 x 10) x Petco(2) - (5 x 5 x 10 + 5 x 5)/(10 x 10) x int time + 2 x 2 x 2 x 2 + (2 x 2)/10, which reduces to 0.65 x Petco(2) - 2.75 x int time + 16.4. This produced a bias and precision of 0.9 +/- 4.1 mm Hg in the construction group and 0 +/- 3.7 mm Hg in the test group (p < 0.01). CONCLUSIONS: In this study of nonintubated emergency department patients, a genetic algorithm produced an improvement in bias and precision of Paco(2) prediction.

A 2 year experience of nurse led conscious sedation in paediatric burns.

INTRODUCTION: Ketamine and midazolam have been used safely by anaesthetists in paediatric burns and have a good safety profile. We believed that this could be developed to a nurse led conscious sedation protocol, without direct anaesthetic attendance. METHODS: Two years experience of our technique was retrospectively reviewed. We recorded the age, weight, percentage burn, dose of oral ketamine and midazolam given, time for procedure whether an anaesthetist was called to the sedation room, and the reason for the call. RESULTS: Data were collected for a total of 45 children undergoing 131 procedures. The age (mean ± SD) was 9.5 ± 4.7 years, the weight (mean ± SD) 38.7 ± 19.8 kg and the percentage burn (mean ± SD) was 25.3 ± 22.9%. The dose of oral ketamine (mean ± SD) was 409.5 ± 252.3mg or 8.78 ± 3.27 mg/kg and the dose of oral midazolam (mean ± SD) was 17.6 ± 8.7 mg or 0.44 ± 0.14 mg/kg. The duration of procedure (mean ± SD) was 97.32 ± 32.90 min. The incidence of the anaesthetist required to administer further sedation was 29.8% of sedations. The decision to convert to general anaesthesia was taken in 2.3% of cases. An anaesthetist was called other than to top up sedation in 6.9% of sedations. CONCLUSION: Our protocol for nurse-monitored conscious sedation using oral ketamine and midazolam in the burns patient provides a safe method of analgesic sedation for burn dressing changes.

Structure of avian orthoreovirus virion by electron cryomicroscopy and image reconstruction.

Among members of the genus Orthoreovirus, family Reoviridae, a group of non-enveloped viruses with genomes comprising ten segments of double-stranded RNA, only the "non-fusogenic" mammalian orthoreoviruses (MRVs) have been studied to date by electron cryomicroscopy and three-dimensional image reconstruction. In addition to MRVs, this genus comprises other species that induce syncytium formation in cultured cells, a property shared with members of the related genus Aquareovirus. To augment studies of these "fusogenic" orthoreoviruses, we used electron cryomicroscopy and image reconstruction to analyze the virions of a fusogenic avian orthoreovirus (ARV). The structure of the ARV virion, determined from data at an effective resolution of 14.6 A, showed strong similarities to that of MRVs. Of particular note, the ARV virion has its pentameric lambda-class core turret protein in a closed conformation as in MRVs, not in a more open conformation as reported for aquareovirus. Similarly, the ARV virion contains 150 copies of its monomeric sigma-class core-nodule protein as in MRVs, not 120 copies as reported for aquareovirus. On the other hand, unlike that of MRVs, the ARV virion lacks "hub-and-spokes" complexes within the solvent channels at sites of local sixfold symmetry in the incomplete T=13l outer capsid. In MRVs, these complexes are formed by C-terminal sequences in the trimeric mu-class outer-capsid protein, sequences that are genetically missing from the homologous protein of ARVs. The channel structures and C-terminal sequences of the homologous outer-capsid protein are also genetically missing from aquareoviruses. Overall, the results place ARVs between MRVs and aquareoviruses with respect to the highlighted features.

Sequential partially overlapping gene arrangement in the tricistronic S1 genome segments of avian reovirus and Nelson Bay reovirus: implications for translation initiation.

Previous studies of the avian reovirus strain S1133 (ARV-S1133) S1 genome segment revealed that the open reading frame (ORF) encoding the final sigmaC viral cell attachment protein initiates over 600 nucleotides distal from the 5' end of the S1 mRNA and is preceded by two predicted small nonoverlapping ORFs. To more clearly define the translational properties of this unusual polycistronic RNA, we pursued a comparative analysis of the S1 genome segment of the related Nelson Bay reovirus (NBV). Sequence analysis indicated that the 3'-proximal ORF present on the NBV S1 genome segment also encodes a final sigmaC homolog, as evidenced by the presence of an extended N-terminal heptad repeat characteristic of the coiled-coil region common to the cell attachment proteins of reoviruses. Most importantly, the NBV S1 genome segment contains two conserved ORFs upstream of the final sigmaC coding region that are extended relative to the predicted ORFs of ARV-S1133 and are arranged in a sequential, partially overlapping fashion. Sequence analysis of the S1 genome segments of two additional strains of ARV indicated a similar overlapping tricistronic gene arrangement as predicted for the NBV S1 genome segment. Expression analysis of the ARV S1 genome segment indicated that all three ORFs are functional in vitro and in virus-infected cells. In addition to the previously described p10 and final sigmaC gene products, the S1 genome segment encodes from the central ORF a 17-kDa basic protein (p17) of no known function. Optimizing the translation start site of the ARV p10 ORF lead to an approximately 15-fold increase in p10 expression with little or no effect on translation of the downstream final sigmaC ORF. These results suggest that translation initiation complexes can bypass over 600 nucleotides and two functional overlapping upstream ORFs in order to access the distal final sigmaC start site.