Qualitative Assessment of a Medical Protocols Mobile Application at the Boston Marathon 2016.

OBJECTIVE: To examine the creation of a medical protocols mobile application for the Boston Marathon and its use by medical volunteers for the 2016 Boston Marathon. DESIGN: Anonymous questionnaire. SETTING: 2016 Boston Marathon. PARTICIPANTS: Two hundred ninety-four marathon medical volunteers. MAIN OUTCOME MEASURES: Responses regarding ease of use, acceptability, and usefulness of the International Institute of Race Medicine mobile application. RESULTS: In total, 88% of medical volunteers who participated in the study felt that the medical protocols mobile application was easy to use. Approximately 72% would use the app again, and 79% would recommend the app to others. However, only 15% of volunteers consistently used the app during the event, and 37% felt like it contributed to clinical decision-making. CONCLUSIONS: A medical protocols app was found to be useful and well accepted among medical volunteers who reported using the app, but only a minority of respondents used the app on marathon day or felt like it contributed to clinical care. Although new, mobile apps in race medicine should continue to be an area of development as providers increasingly integrate their use into clinical practice.

Comparisons of screening colonoscopy performed by a nurse practitioner and gastroenterologists: a single-center randomized controlled trial.

Several barriers to colorectal cancer screening have been identified including limited access to trained endoscopists and highlight insufficient capacity to meet projected demand for colonoscopies. Two European studies have found that nonphysician providers can perform colonoscopies as safely and accurately as physicians. Training nurse practitioners (NP) to perform colonoscopy may be an effective strategy to increase access. The goal of this study was to compare accuracy, safety, and patient satisfaction in screening colonoscopy performed by board certified gastroenterologists (GI-MD) and a gastroenterology trained nurse practitioner (GI-NP). A consecutive sample of average risk participants referred for screening colonoscopy was randomized to have their procedure performed by either a GI-MD (n = 100) or a GI-NP (n = 50). Participants completed a preprocedure and postprocedure questionnaire. Endoscopists completed a postprocedure questionnaire. Cecal intubation rates, duration of procedure, sedative, and analgesic use, and patient reported procedural pain scores were equivalent among the groups. The GI-NP group had a higher adenoma detection rate compared with the combined GI-MD groups (42% and 17%, respectively, p = .0001) and a higher satisfaction score when compared with the combined GI-MD groups (mean 5.9 ± 13.81 and 8.6 ± 16.11, respectively, p = .042; visual analog scale 0-100 mm, "0" = completely satisfied, "100" = completely dissatisfied). There were no immediate complications reported in any group. The properly trained GI-NP in our study performed screening colonoscopy as safely, accurately, and satisfactorily as the GI-MDs. Using well-trained NPs for screening colonoscopy can be an effective strategy to increase access to colorectal screening.

Air exposure induced squamous metaplasia of human limbal epithelium.

PURPOSE: Squamous metaplasia is a pathologic process that frequently occurs in nonkeratinized stratified ocular surface epithelia. The mechanism for this occurrence is largely unknown except for vitamin A deficiency. METHODS: Human limbal explants were cultured under airlift with or without p38 mitogen-activated protein kinase (MAPK) inhibitor SB203580 or in a submerged manner for different durations up to 2 weeks. Epithelial cell proliferation, differentiation, limbal stem cell maintenance, and expansion were studied using certain markers such as Ki67, p63, K10 and K12 keratins, filaggrin, Pax6, ABCG-2, and Musashi-1. Expression of phospho-p38 MAPK and its downstream transcription factors, C/EBPalpha and C/EBPbeta, were studied by immunohistochemistry. Epithelial cells harvested from explants after 2 weeks of culturing under different conditions were seeded onto 3T3 feeder layers and cultured for 12 days. The differentiation of clonal epithelial cells was investigated by double staining to K12 and K10 keratins. RESULTS: The squamous metaplasia model was successfully created by culturing human limbal explants at an air-liquid interface (airlift) for 2 weeks. Increased stratification and hyperproliferation only happened in the limbal, but not the corneal, epithelium in airlift, but not submerged, cultures. Epithelial proliferation was associated with a transient increase of limbal epithelial stem cells. Abnormal epidermal differentiation-evidenced by positive expression of K10 keratin in suprabasal cells and filaggrin in superficial cells-ensued. Clones generated from epithelial cells harvested from airlift culture only expressed K12 keratin without K10. As early as 2 days in airlift cultures, p38 expression emerged in limbal basal epithelial cells and gradually extended to the cytoplasm and nuclei. Furthermore, addition of the p38 inhibitor SB203580 abolished abnormal epidermal differentiation without affecting limbal epithelial proliferation. Expression of C/EBPalpha and C/EBPbeta, downstream of the p38 MAPK signaling pathway, was strongly induced by airlift culture and partially was inhibited by SB203580. CONCLUSIONS: Dryness resulting from exposure activates p38 MAPK signaling coupled with abnormal epidermal differentiation without intrinsic alteration of stem cells in the limbus. On the ocular surface, p38 inhibitors may have the potential to revert the pathologic process of squamous metaplasia induced by dryness.

Biochemical characterization and function of complexes formed by hyaluronan and the heavy chains of inter-alpha-inhibitor (HC*HA) purified from extracts of human amniotic membrane.

Clinically, amniotic membrane (AM) suppresses inflammation, scarring, and angiogenesis. AM contains abundant hyaluronan (HA) but its function in exerting these therapeutic actions remains unclear. Herein, AM was extracted sequentially with buffers A, B, and C, or separately by phosphate-buffered saline (PBS) alone. Agarose gel electrophoresis showed that high molecular weight (HMW) HA (an average of approximately 3000 kDa) was predominantly extracted in isotonic Extract A (70.1 +/- 6.0%) and PBS (37.7 +/- 3.2%). Western blot analysis of these extracts with hyaluronidase digestion or NaOH treatment revealed that HMW HA was covalently linked with the heavy chains (HCs) of inter-alpha-inhibitor (IalphaI) via a NaOH-sensitive bond, likely transferred by the tumor necrosis factor-alpha stimulated gene-6 protein (TSG-6). This HC.HA complex (nHC*HA) could be purified from Extract PBS by two rounds of CsCl/guanidine HCl ultracentrifugation as well as in vitro reconstituted (rcHC*HA) by mixing HMW HA, serum IalphaI, and recombinant TSG-6. Consistent with previous reports, Extract PBS suppressed transforming growth factor-beta1 promoter activation in corneal fibroblasts and induced mac ro phage apoptosis. However, these effects were abolished by hyaluronidase digestion or heat treatment. More importantly, the effects were retained in the nHC*HA or rcHC*HA. These data collectively suggest that the HC*HA complex is the active component in AM responsible in part for clinically observed anti-inflammatory and anti-scarring actions.

Human amniotic epithelial cells as novel feeder layers for promoting ex vivo expansion of limbal epithelial progenitor cells.

Human amniotic epithelial cells (HAECs) are a unique embryonic cell source that potentially can be used as feeder layers for expanding different types of stem cells. In vivo, HAECs uniformly expressed pan-cytokeratins (pan-CK) and heterogeneously expressed vimentin (Vim). The two phenotypes expressing either pan-CK(+)/Vim(+) or pan-CK(+)/Vim(-) were maintained in serum-free media with high calcium. In contrast, all HAECs became pan-CK(+)/Vim(+) in serum-containing media, which also promoted HAEC proliferation for at least eight passages, especially supplemented with epidermal growth factor and insulin. Mitomycin C-arrested HAEC feeder layers were more effective in promoting clonal growth of human limbal epithelial progenitors than conventional 3T3 murine feeder layers. Cells in HAEC-supported clones were uniformly smaller, sustained more proliferation, and expressed less CK12 and connexin 43 but higher levels of stem cell-associated markers such as p63, Musashi-1, and ATP-binding cassette subfamily G2 than those of 3T3-supported clones. Subculturing of clonally expanded limbal progenitors from HAEC feeder layers, but not from 3T3 feeder layers, gave rise to uniformly p63-positive epithelial progenitor cells as well as nestin-positive neuronal-like progenitors. Collectively, these results indicated that HAECs can be used as a human feeder layer equivalent for more effective ex vivo expansion of adult epithelial stem cells from the human limbus. Disclosure of potential conflicts of interest is found at the end of this article.